Yukon Workers' Compensation Health & Safety Board
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Worker's Report of Injury/Illness

 This information is being collected under the
authority of the Workers' Compensation Act for
the purpose of determining eligibility for benefits.
For further information, please call (867) 667-8796.
 

Tell Us About You

To ensure we can process your claim quickly, please complete this form as
thoroughly as possible.
A red dot = required
A red dot Worker's Name: 
  first m last
 
A red dot Gender: 
 
Mailing Address: 
  street, city, province or territory, postal code
What is your home address?
A red dot Date of birth: 
  day month year
 
Home Telephone Number: 
What is your home telephone number?
Work Telephone Number: 
Do you have a direct telephone line at work?
Cell Number: 
Do you have a cell phone?
Email Address: 
What is your primary email address? We’ll use this address to contact you.
A red dot Social Insurance Number: 
 
Worker’s Occupation: 
What is your job?
Name of supervisor: 
What is your supervisor’s name?
Supervisor’s telephone number: 
What is your supervisor’s phone number?
Supervisor’s cell number: 
What is your supervisor’s cell phone number?
A red dot Employer’s name and address (include government department if applicable): 
 

Tell Us About Your Injury/Illness
A red dot In your own words, what happened? 
Describe how you were injured.
What part of your body was injured? (Please indicate left or right side.)
 If you were physically injured, identify what part of your body was injured.
Have you hurt this part of your body before?
If you had a similar injury before identify it here
Date of injury/illness: 
  day month year
 
If your injury/illness occurred over time, when did you first experience symptoms?
day month year
 
Who did you report the injury/illness to?
 Provide the name of the person you initially reported your injury/illness to
When did you report the injury/illness?
day month year
 
What were your hours of work on the day of the injury/illness?
from   to  		 
What equipment was being used?
  
Was first aid given at the work site? 
 
Were you doing work for your employer when the injury occurred?
 
Did the injury/illness happen on your employer’s premises?
 
Did you seek medical attention beyond first aid at the work site?
 
If so, where?
  
When? 
  day month year
 
Who treated you?
  
A red dot Did you miss work after the date of injury/illness?
 
A red dot Have you returned to work?
 
If Yes, when? 
  day month year
 

About Your Information
A red dot Your name:
 In place of a signature, please verify your identity.