Worksafe Bc Form 55M5 PDF Details

Worksafe BC has released a new form, Form 55M5, which will be used to report serious injuries or fatalities. The new form is required for all incidents that meet the definition of 'serious injury' or 'fatalities'. Employers are responsible for completing and submitting the form within 48 hours of the incident. The purpose of the new form is to provide Worksafe BC with accurate and timely information about serious injuries or fatalities. The deadline for submitting Form 55M5 is fast approaching, so employers should ensure they are familiar with the new form and understand its requirements. failure to comply could result in significant penalties. For more information on what constitutes a serious injury or fatality, please visit our website or contact us at 1-

Question	Answer
Form Name	Worksafe Bc Form 55M5
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	elevations, certificationworksafebc, immobilize, pallor

Form Preview Example

	OCCUPATIONAL FIRST AID
	MEDICAL CERTIFICATE OF FITNESS
	Report of Examining Physician
CERTIFICATION SERVICES	EMAIL
Phone 604 276-3090	certification@worksafebc.com
Toll-free 1 888 621-7233, ext. 3090

Examining physician, please note:

1.The fee for the services of the physician is the responsibility of the candidate.

2.It is essential that the candidate be PHYSICALLY and PSYCHOLOGICALLY fit to perform the duties of an occupational first aid attendant.

Please print

Surname of candidate		Given name(s) in full			Mr.	Ms.
					Mrs.	Miss

Mailing address				Date of birth (yyyy-mm-dd)

City				Province	Postal code


1. Disease conditions — Is there MEDICAL EVIDENCE and/or a HISTORY of
Seizure disorder	Yes	No	Respiratory disease	Yes		No
Hernia	Yes	No	Heart disease	Yes		No
Communicable disease	Yes	No	Multiple sclerosis	Yes		No
Diabetes	Yes	No	Other (not otherwise specified)	Yes		No
If yes, please explain if this disease could affect the candidate’s ability to perform the duties of an
occupational first aid attendant

2. Alcohol or substance abuse — Has the candidate experienced any problems in the PREVIOUS12 MONTHS,
relative to the overuse and/or addiction to ALCOHOL, RECREATIONAL or PRESCRIPTION DRUGS,
and/or OVER-THE-COUNTER MEDICATION?				Yes		No
If yes, please explain

3. Psychological and/or emotional illness — At the work site, first aid attendants may be involved in stressful,
emotional, and/or tense situations. Has the candidate exhibited and/or experienced any PSYCHOLOGICAL
OR EMOTIONAL episode which could preclude the candidate from performing the duties of an
occupational first aid attendant?				Yes		No
If yes, please explain

4. Visual acuity — Would the candidate (with appropriate visual correction, if required) be able to observe an
accident scene from a distance, assess minor wounds, remove small slivers, remove small particles from
the eye, and/or assess a patient for pallor and contusions?				Yes		No
If no, please explain

5. Hearing acuity — Would the candidate (with appropriate hearing correction, if required) be able to hear a
summons for first aid, hear and assess breathing on a patient who may not be visible to him/her (i.e., is out
of sight), distinguish if there is distressed breathing, and/or verbally communicate with a patient?				Yes		No
If no, please explain

55M5	Workers’ Compensation Board of B.C.			(R08/12) Page 1 of 2

Occupational First Aid Medical Certificate of Fitness (continued)

Surname of candidate

Given name(s)

6. Fine motor skills — upper limbs— Does the candidate have a MOTOR OR SENSORY impairment of
one or both of the upper extremities which could impair his/her ability to assess a pulse, palpate for point
tenderness, remove particles from the eye, immobilize a limb, assess and treat open wounds?	Yes
If yes, please explain

7. Physical fitness — First aid attendants may have to traverse rough terrain such as steep banks, climb over
fallen trees or logs, access areas such as excavations or high elevations. Does the candidate have a
physical condition which could limit his/her ability to render first aid under these conditions?	Yes
If yes, please explain

8. Lifting ability — First aid attendants may have to assist in transporting a patient, secured to a lifting device,
over rough terrain. They may also have to carry equipment weighing up to 50 lb. (22.680 kg). Does the
candidate have a physical condition which could limit his/her ability to render first aid under these conditions?	Yes
If yes, please explain

9. Medication — Is the candidate taking any medication which could affect his/her ability to render first aid?

Yes

If yes, please explain

10. Professional opinion — In summary, in your professional opinion, do you have confidence in this candidate’s
PHYSICAL and/or PSYCHOLOGICAL FITNESS to render emergency pre-hospital care to workers?	Yes
If no, please explain

Physician’s name (please print)

Physician’s signature

Phone number (include area code)

Street address

City

Province

Postal code

Date (yyyy-mm-dd)

Clinic or physician’s stamp


Candidate’s statement
I have answered all questions from my physician, Dr.		, honestly and truthfully, and I was
forthcoming with Dr.	regarding any physical or mental condition that would have a
bearing upon my PHYSICAL or MENTAL ASSESSMENT.

Candidate’s signature

Date (yyyy-mm-dd)

55M5	(R08/12) Page 2 of 2

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Worksafe Bc Form 55M5 – Fill Out and Use This PDF

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