If you were involved in a recent work place accident and want to claim it as a WorkSafe injury, please fill in the following form below. You can either print it off and fill it in with pen, or fill it in on the computer and email it to firstname.lastname@example.org. Please let our staff know that you were involved in a work place accident so we book extra time for the examination.
The last two pages of the intake form are required surveys by WorkSafeBC. They are used to monitor your progress with treatment, so try to be as accurate as possible and complete all boxes. Keep in mind that the Neck Disability Index only applies to neck pain (only complete it if you have neck pain), and the Oswestry Disability Index only applies to back pain (only complete it if you have back pain).
Work Place Injury (WCB) Intake Form