Use this form when:
You have a work-related injury / incident or recurring work-related injury or illness that results in any of the following:
- medical attention;
- loss of earnings; and / or
- lost-time from work.
This includes injuries or illnesses that occurred over time as well as those caused by an event.
If you feel your current symptoms are related to a previous work injury, complete this form based on your current situation, as opposed to restating what happened at the time of your initial injury. For example, for question 4 under section B “Date/time of injury/incident,” enter the date and time your current symptoms developed or the date a new incident happened which caused your current symptoms.
If you are a partner, proprietor or independent operator (also referred to as owner/operator on this form) and you have experienced a work- related injury, coverage will be extended only when optional personal coverage has been purchased from WorkplaceNL.
Points to remember:
- Complete and accurate information is important to avoid delays in processing your claim.
- If you have additional information, attach additional pages and include your name and SIN on each page.
- Sign page 2 so we can process your claim.
Section A General Information
Occupation & Employer Information
This refers to your occupation and employer at the time of your injury / incident.
Section B Injury / Incident Information
How did your injury / incident occur or the condition develop?
Explain how the injury / incident happened and what you were doing at that time. This may include information such as: sizes, weights and names of objects involved; description of any machinery, tools or vehicles used at the time of the injury / incident; environmental conditions (work area, temperature, noise, chemicals, gas, fumes); if another person was involved; or any other information you think is important.
For example: “I was moving boxes in the storage room. I lifted a 40-pound box from the floor to put on a shelf. I twisted to the right while lifting, and hurt my upper back.”
If your condition developed over time, a detailed description of the work you do is helpful. Explain how often you do a particular task; the sizes and weights of objects involved; how long you have been doing this work; and if there have been any recent changes to your schedule and / or tools or products you use.
For example: “I am a cashier and continuously scan products for my eight-hour shift using my left arm. The products can weigh from a few ounces up to 10 pounds. The belt hasn’t been working properly for the past three weeks and I reach further than I usually do to ring things in. Recently I started to have pain in my left elbow.”
Did the injury / incident happen on the employer’s property or worksite?
Detailed information as to where the injury / incident happened is important to process your claim. For example, if on the employer’s premises, where did it occur? The shipping area, paint shop, or warehouse? If not on the employer’s premises, where did it happen?
For example: “I work for a cleaning company and was working at a retail store when the injury happened. The store was ABC Clothing on Anywhere Street.”
Section D: Return-to-work Information
You and your employer may be able to change your duties and / or hours so you can stay at work while you are receiving medical treatment for your injury. This is called early and safe return-to-work.
An early and safe return-to-work plan should be developed in co-operation with your employer, based on the functional abilities information from your health care provider(s).
Section E: Earnings Information
If you are off work for more than one day, or have an early and safe return-to-work plan of more than one day, you may be entitled to wage-loss benefits. You should complete this section so WorkplaceNL can make this determination.
Section H: Signature, Consent and Declaration
Signing the Form 6 Consent enables WorkplaceNL to process your claim.
For more information on your rights and our personal information practices please see our Personal Information Privacy Statement, available on line or by contacting WorkplaceNL.
Additional Worker Information
Worker’s role in early and safe return to work
The main focus of early and safe return to work is to enable you to remain at the workplace following an injury or to return to the workplace in a safe and timely manner if you have already lost time from work.
Going back to work may involve making changes to the duties and/or the hours of work. It may also involve changes to the workplaces such as acquiring equipment or other devices to help you with your return to work.
Staying in touch with work
It is important to stay connected to your workplace following an injury. If your injury prevents you from performing your regular job duties, both you and your employer are required to work together to identify suitable and available employment, even while you are receiving medical treatment for your injury.
During each medical appointment, your doctor will provide you with a copy of their report (form MD) for your records and a second copy to bring to your employer. The employer’s copy of the doctor’s report does not contain your personal medical information; it simply identifies your functional abilities as a result of the injury.
It is extremely important for you to provide this report to your employer by the next working day after each doctor’s visit. This will enable you to assist your employer in identifying suitable job duties so you can continue working without aggravating your injury. If you work in a unionized environment, you may want to involve your union representative in this process.
Finding the right duties
When identifying early and safe return-to-work opportunities with your employer, the first priority should be to maintain the connection to your pre-injury job at some level. Where this is not possible, it is important to work with your employer to identify suitable and available employment that is within your physical capabilities. If you and your employer require any assistance during this process, you should contact your case manager.
Documenting a plan
Once you and your employer have identified suitable job duties that are in keeping with your abilities, you will complete an early and safe return-to-work plan that outlines the agreed upon schedule and progression of duties. If any change occurs to this plan, you must immediately notify your case manager. Your early and safe return-to-work plan should also outline the scheduled hours and the hourly wage earned. This information will then be used to determine if there is any entitlement to compensation during your return-to-work process.
Communication is critical during early and safe return to work. The frequency and method of communication between you and your employer will be determined by the employer’s procedures. However, we recommend you contact your employer weekly during the early and safe return-to work-program. You should contact them immediately if there is an improvement or deterioration in your physical condition that could affect your return-to-work plan. It is also important to keep your case manager updated on your progress.
Worker’s role in occupational health and safety (OHS)
- Protect your health and safety and that of co-workers and others at or near the workplace;
- Co-operate with your employer, co-workers, OHS committee/worker health and safety representative/workplace health and safety designate, and anyone exercising a duty imposed under OHS legislation;
- Follow instructions and training;
- Report hazardous conditions; and
- Properly use all safety equipment, devices and clothing.
- Know about workplace hazards;
- Participate and assist in identifying and resolving OHS issues; and
- Refuse unsafe work.