Wsib Form Progress Report 41 PDF Details

In the realm of workplace safety and insurance, the WSIB Progress Report 41 form serves as a vital tool for individuals navigating through the process of reporting and managing their injury or illness claims. This detailed document is designed to communicate a worker's current condition and treatment status directly to the Workplace Safety and Insurance Board (WSIB), ensuring that all parties are updated on the progress towards recovery. Workers are required to provide comprehensive information, including any changes in their health status, details of their treatment by healthcare professionals, any new referrals for tests or specialists, and the use of medication or assistive devices. Furthermore, the form delves into employment status, inquiring whether the injured or ill person has engaged in any work since the initial incident, thereby addressing aspects of employment and financial stability post-accident. Questions related to return to work, such as discussions with health professionals and employers about work limitations or functional abilities, the nature of the work returned to, and any barriers preventing return to work, are crucial parts of this document. Importantly, the form emphasizes honesty and the legal implications of submitting false information, reinforcing the integrity of the process. Suitable for mailing or faxing, this form facilitates ongoing communication between workers and the WSIB, playing a crucial role in the claim management process.

QuestionAnswer
Form NameWsib Form Progress Report 41
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswsib progress report form 26, workers progress report, wsib form41, wsib progress

Form Preview Example

 

 

 

 

 

 

 

Mail To:

OR Fax To:

41

Worker's

 

 

 

 

 

 

 

200 Front Street West

416-344-4684

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Toronto ON M5V 3J1

OR 1-888-313-7373

 

 

Progress Report (Form 41)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Number

 

 

 

 

Please PRINT in black ink

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Worker's Name

 

 

 

Original Date of Accident/Injury

 

Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

Accident Employer

 

 

 

If any information is incorrect, please provide the changes here:

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Please check which status best

Describe any details or changes to your condition

 

 

 

 

 

 

describes your current condition

 

 

 

 

 

 

 

 

 

Recovered

 

Getting Better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Change

 

Getting Worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Who is the primary health professional directing your current treatment?

mm yy

 

dd mm yy

 

 

 

 

 

 

 

 

dd

 

 

 

Name

 

 

 

Date of

 

 

Date of

 

 

 

 

 

 

 

 

last visit

 

 

next visit

3.Please specify any referrals you have not yet reported to the WSIB

no new referrals

 

testing (e.g. labs, x-rays, CT Scan, MRI, etc.)

 

specialist

 

other (specify)

 

 

 

 

 

 

 

Name/Facility

dd mm yy

Date of that appointment

4.

Are you presently taking any drugs/medications or using an assistive device/brace for this injury?

 

yes

 

no

 

If yes, list names

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Have you worked for any employer(s) or were you self employed between the first day off and now?

 

yes

 

no

 

 

 

 

 

 

 

If yes, provide details including dates, name/address of employer/company

 

 

 

 

6.Choose one of the following that best describes your current situation. For this claim,

I have not lost any time or pay from work (complete only question 7)

I have lost time and/or pay and have returned to work (complete only questions 7 and 8)

I have lost time and have not returned to work (complete only questions 9 to 12)

7.

Was your return

a)

 

regular work

OR

 

 

modified work

8.

Date of your

 

 

dd

mm

yy

 

 

 

 

 

 

 

 

 

 

to work to

 

 

 

 

 

 

 

 

b)

 

regular pay

OR

 

 

lower pay

 

 

return to work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c)

 

regular hours

OR

 

 

less hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Have you talked to your health professional about return to work?

 

10.

Have you talked to your employer about return to work?

 

 

 

 

yes

 

 

no

 

If yes, date of

dd

mm

yy

 

 

 

 

yes

 

 

no

 

 

dd

mm

yy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, date of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

last discussion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

last discussion

 

 

 

 

 

and have they determined

 

 

 

yes

 

 

 

no

name of person

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

your work limitations or functional abilities?

 

 

 

 

 

 

you talked to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Has any type of work been offered to you?

 

 

 

yes

 

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, provide details

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

 

Are there any other factors that are preventing you from returning to work?

 

 

 

 

yes

 

 

 

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes,

provide details

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

It is an offence to deliberately make false statements to the Workplace Safety and Insurance Board. I declare that all of the information provided on this page is true.

Signature

Date dd/mm/yy

0041A (03/08)

www.wsib.on.ca

41

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Completing segment 1 in form 41

2. Immediately after this part is completed, go to enter the relevant information in all these - Are you presently taking any, yes, If yes list names, Have you worked for any employers, yes, Choose one of the following that, I have not lost any time or pay, Was your return, to work to, a b c, regular work regular pay regular, OR OR OR, modified work lower pay less hours, Have you talked to your health, and yes.

The right way to fill in form 41 part 2

Regarding Have you talked to your health and yes, be certain you don't make any mistakes in this section. These are the most important ones in this PDF.

3. This 3rd step is considered pretty uncomplicated, Has any type of work been offered, yes, Are there any other factors that, yes, It is an offence to deliberately, Signature, Date ddmmyy, and wwwwsibonca - these empty fields is required to be filled in here.

Writing segment 3 in form 41

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