Wcb Form C060 PDF Details

The Workers' Compensation Board (WCB) C060 form, a critical document for employees who have suffered an injury or an occupational disease in Alberta, Canada, serves as the primary means by which workers can report their injury or condition to initiate a claim for compensation. This comprehensive form requires detailed information from the injured worker, including personal details, specifics of the injury or disease, employment information, and the circumstances surrounding the accident or condition development. Significantly, it also asks for an in-depth account of the accident, the initial medical treatment received, and the worker's employment status, such as whether they have been off work or if their duties have been modified post-incident. Moreover, it addresses the worker's understanding and obligations towards a safe and healthy return to work, a pivotal component of the rehabilitation process. It is pertinent for the worker completing this form to provide truthful and accurate information, as discrepancies might lead to penalties or affect the outcome of the claim. The form also touches upon the importance of the worker's cooperation in providing additional information if requested and indicates the legal and privacy considerations in processing the claim. The procedure outlined by the WCB aims to ensure that workers receive the support and compensation they deserve while maintaining transparency and integrity throughout the process.

QuestionAnswer
Form NameWcb Form C060
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesalberta workers report, wcb alberta workers, wcb workers, form wcb workers form

Form Preview Example

P.O. BOX 2415

EDMONTON AB T5J 2S5

Phone 780-498-3999 (in Edmonton)

1-866-922-9221 (toll free in Alberta)

1-800-661-9608 (outside Alberta)

Fax

780-427-5863 or 1-800-661-1993

APRIL 2021

WORKER REPORT

of Injury or Occupational Disease

C060

Seven digit claim #:

Worker Details

Past the date of injury: Have you been off work?

Yes

No

1 Have your work duties been modified?

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last name:

 

 

 

 

First name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing address: Apt# _____ ,

 

 

 

Social Insurance #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

Province:

Postal code:

 

Personal health #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone number:

 

 

 

Date of birth:

 

 

 

(Year / Month / Day)

 

Gender:

 

M

F

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email address:

Occupation and job description:

Are you an apprentice?

Yes

No

If yes, date you would have obtained journeyman status:

(Year / Month / Day)

Date hired:

 

 

(Year / Month / Day)

 

 

 

 

 

 

 

 

 

 

Are you a partner or director in the business?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have personal coverage?

Yes

 

 

No

 

If yes, coverage number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Details

 

 

2 Employer business name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

Province:

 

Postal code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact name:

 

 

 

 

Title:

 

 

 

 

 

 

 

Phone:

 

E-mail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accident Details

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 Date/time of accident:

 

 

 

 

 

 

 

(Year / Month / Day)

 

 

 

 

 

 

Time: ___ ___ : ___ ___

a.m.

p.m.

or

the injury/condition developed over time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date/time scheduled shift started (if applicable):

 

 

 

 

 

(Year / Month / Day)

 

Time: ___ ___ : ___ ___

a.m.

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date/time scheduled shift ended (if applicable):

 

 

 

 

 

(Year / Month / Day)

 

Time: ___ ___ : ___ ___

a.m.

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4Date accident/injury reported to employer:

(Year / Month / Day)

Name of person and their position:

Phone number:

If not reported immediately, give the reason:

5Describe fully, based on the information you have, what happened to cause this injury or disease. Please describe what you were doing, including details about any tools, equipment, materials, etc. you were using. State any gas, chemicals or extreme temperatures you may have been exposed to:

 

Cardiac condition/injury?

 

Claimed to another WCB? Province: ____________________________________

 

 

 

Motor vehicle accident? If you have a police collision report, please send a copy by mail or fax once you have a claim number. Please also complete the WCB Automobile Accident Report.

If you have more information or a list of witnesses, please attach a letter. Please check this box if letter is attached.

Have you had a similar injury before?

Yes

No If yes, attach a letter with details.

Was the work you were doing for the purpose of your employer’s business?

Yes

No

Was it part of your usual work?

Yes

No

Did the accident/injury occur on employer’s premises?

Yes

No

Location where the accident happened (address, general location or site):

6Full name of treating hospital or healthcare professional: Address:

Phone:

When did you first seek medical treatment?

(Year / Month / Day)

Is any further treatment required?

Yes

No

Complete all three pages and sign the form before sending.

If your injury is the result of a motor vehicle accident, complete the Automobile Accident Report (L-054).

REV APR 2021

WORKER REPORT

 

Page 2 of 3

 

 

 

Worker’s last name:

Worker’s first name:

Initial:

Social Insurance #:

Date of birth:

(Year / Month / Day)

Injury Details

What part of body was injured? (hand, eye, back, lungs, etc.)

Left side

Right side

What type of injury is this? (sprain, strain, bruise, etc.)

Return to Work Details

Please complete all that apply

I understand I have a duty to cooperate with WCB in arranging my safe and healthy return to work with my employer.

7a. Will/did your employer pay you while off work?

Yes, pre-accident wages

Yes, revised rate of pay

Revised rate of pay: $ ______________ per _________

No

Unknown

b. Date you first missed work:

(Year / Month / Day)

(Year / Month / Day)

c. If you have returned to work indicate date:

Current work status:

 

Regular work duties, or

 

Modified work duties

 

Regular hours of work, or

 

Modified hours of work: _______ hrs per ________

If you are working modified duties please describe:

(Year / Month / Day)

Approximate date you expect to return to work:

Is your expected return to work:

Within 2 weeks

2-8 weeks

2-6 months

6+ months

Unknown

Employment Type Details (Complete A or B or C. Select your type of employment.)

8 A Permanent position employed 12 months of the year:

Permanent full-time

Permanent part-time

Irregular/casual

or B Non-permanent position employed only part of the year (subject to seasonal or lack of work layoffs):

 

Seasonal worker

 

Summer student

Temporary position

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Had this injury not occurred, your last day of employment would have been:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position start:

 

 

(Year / Month / Day)

 

 

 

Position end:

 

 

 

(Year / Month / Day)

 

 

 

 

Estimated, or

Actual

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How many months or days are workers employed in this position? ________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or C Special employment circumstance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sub contractor

Vehicle owner/operator

Welder owner/operator

Commission

 

Piece work

 

Volunteer

Self-employed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you incur expenses to perform the work (materials, tools, etc.)?

Yes

 

No

Will you receive a T4?

Yes

No

 

Note: If you have checked any box in 8C please submit a detailed income and expense statement.

Earning Details

a. Your rate of pay at time of accident: $

per

Hour

Day

Week

Month

Year

9b. Additional taxable benefits:

Vacation pay:________________

 

Taken as time off with pay

 

Paid on a regular basis %

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shift premium

Please describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Overtime

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Do you have a second job?

(Second employer may be contacted)

Yes

No If yes – Employer’s name:

Phone:

d. Did you miss time from this second job?

Yes

No

If yes, please attach earning information and time missed details.

Complete all three pages and sign the form before sending.

REV APR 2021

Please fill in your name, Social Insurance Number and date of birth at the top of

each page of the form in case the pages get separated.

Remember to complete all three pages and sign the form before sending.

WORKER REPORT

Page 3 of 3

Worker’s last name:

Social Insurance #:

Worker’s first name:

Initial:

(Year / Month / Day)

Date of birth:

Hours of Work Details

10a. Number of hours (not including overtime):

per week

Describe your work schedule (e.g., Monday to Friday, on. Saturday to Sunday, off.):

Declaration and Consent

I declare that the information in the Worker Report of Injury or Occupational Disease form will be true and correct.

I understand that:

•While I am receiving any benefits from WCB-Alberta, it is my obligation to inform WCB-Alberta immediately if I return to work of any kind, become capable of working or if there is any other change in my employment status. Work includes but is not limited to any activity in which labour or services are provided, whether or not payment of any kind is received.

•Criminal prosecution may result from any attempt on my part to collect benefits by providing false information, failing to provide information regarding my ability to work, or other fraudulent means.

•My employer may request a review or appeal of any decisions made on my claim and may therefore examine my claim file. My claim file may also be examined by anyone with a direct interest, as determined by WCB-Alberta, or a person or company I have authorized to review my claim file. (To provide authorization, use the Worker’s Information Release form in the Worker Handbook).

•My social insurance number may be used for reporting to Canada Revenue Agency.

•WCB-Alberta may collect information that it considers relevant to determine benefit entitlement, including information pre-dating my accident, from any source including physicians, other health care providers, employer(s) and vocational rehabilitation service providers. This information is collected to determine my entitlement to compensation under the Workers’ Compensation Act.

WCB-Alberta may use and disclose the information collected to determine entitlement, to provide services and benefits and, as required or authorized by law.

This information may be used and disclosed pursuant to the Workers’ Compensation Act and the Freedom of Information and Protection of Privacy Act.

(Year / Month / Day)

Date:

Name (please print): ________________________________________________

Signature: __________________________________________________________________________________

Signing the above consent enables the Workers’ Compensation Board to process your claim.

NOTE: The information required in the Worker Report of Injury or Occupational Disease is collected under sections 33(a) and (c) of the Freedom of Information and Protection of Privacy Act for the purpose of determining entitlement to compensation and for determining employers’ premium rates. Questions may be directed to the Claims Contact Centre as noted on the front of this form and on the back of the Worker Handbook. The information provided to the Workers’

Compensation Board is protected by the provisions of the Freedom of Information and Protection of Privacy Act.

If your injury was sustained in an automobile accident, fill out and send an

Automobile Accident Report along with the Worker Report.

REV APR 2021

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This PDF requires specific data to be filled in, therefore make sure you take some time to type in what's expected:

1. To start with, when completing the wcb workers form, begin with the area that contains the following blank fields:

Step no. 1 of completing wcb worker report

2. Given that this array of fields is done, you need to put in the required specifics in Datetime scheduled shift ended if, Date accidentinjury reported to, Year Month Day, Year Month Day, Time, Name of person and their position, Phone number, If not reported immediately give, Describe fully based on the, Cardiac condition injury, Claimed to another WCB Province, Motor vehicle accident If you have, complete the WCB Automobile, If you have more information or a, and Have you had a similar injury so you can proceed to the third step.

If not reported immediately give, Have you had a similar injury, and If you have more information or a in wcb worker report

3. The next part is pretty simple, Address, Phone, When did you first seek medical, Year Month Day, Is any further treatment required, Yes, REV APR, and Complete all three pages and sign - each one of these fields has to be completed here.

Yes, When did you first seek medical, and REV APR of wcb worker report

4. This next section requires some additional information. Ensure you complete all the necessary fields - WORKER REPORT, Workers last name, Social Insurance, Workers first name, Initial, Date of birth, Year Month Day, Page of, Injury Details, What part of body was injured hand, Left side, Right side, What type of injury is this sprain, Return to Work Details, and Please complete all that apply - to proceed further in your process!

Filling in segment 4 of wcb worker report

5. The very last step to conclude this PDF form is integral. Be sure to fill out the required form fields, and this includes or B Nonpermanent position, Seasonal worker, Summer student, Temporary position, Had this injury not occurred your, Position start, Year Month Day, Position end, Year Month Day, Estimated or, Actual, How many months or days are, or C Special employment, Sub contractor, and Vehicle owneroperator, before using the pdf. Failing to do this might give you an unfinished and potentially unacceptable paper!

The right way to prepare wcb worker report step 5

Always be really careful while filling out or C Special employment and Year Month Day, because this is the section in which many people make mistakes.

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