Wsib Form Progress Report 41 PDF Details

WSIB Form Progress Report 41 is now available for preview on the WSIB website. This new form replaces Form 31 and is intended to provide a more streamlined experience for workers and employers. The form is divided into two parts, with the first section designed for workers to report their injury or illness, and the second section intended for employers to submit their return-to-work plans. There are also several new features in this version of the form, including checkboxes to indicate whether an injury is Work-Related or Not Work-Related, as well as a place to enter the date of injury. WSIB representatives suggest that employers review the form in its entirety before using it in order to become familiar with all of its features.

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

How to Edit Wsib Form Progress Report 41 Online for Free

wsib form41 can be filled out online effortlessly. Just try FormsPal PDF editor to complete the job quickly. The tool is constantly improved by us, getting awesome functions and becoming a lot more convenient. With some easy steps, you can start your PDF editing:

Step 1: Access the form in our tool by pressing the "Get Form Button" in the top section of this page.

Step 2: This editor will let you work with PDF files in a variety of ways. Enhance it by writing personalized text, adjust what's originally in the PDF, and place in a signature - all readily available!

It is actually simple to fill out the pdf adhering to this helpful tutorial! Here is what you should do:

1. It is advisable to fill out the wsib form41 accurately, therefore be attentive when filling out the parts including these specific blank fields:

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

Step 3: Immediately after rereading the fields, hit "Done" and you are good to go! Right after creating afree trial account with us, you'll be able to download wsib form41 or email it right away. The file will also be available from your personal account menu with your adjustments. We do not share or sell any information that you type in whenever working with forms at our site.