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WorkSafeBC

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Forms inquiries

Customer Support Centre

Phone 604 276-3135
Toll-free 1 888 855-2477

Select a tab below to find forms for employers, workers, or health care providers. Most forms are PDFs designed to be printed out and completed. Others can be completed and submitted online, and some are available as an online application. Printed forms can also be ordered from the WorkSafeBCstore. New versions of claim-related forms available now.

WorkSafeBC Forms

Form# Name Updated
6A Worker's report of injury or occupational disease to employer (PDF 177kb/2 pages)
Provided here so employers can give to workers.		 R06/08
6/7 Independent operator's application for compensation and report of injury or occupational disease (PDF 76kb/2 pages) R06/08
7 Online incident and injury report  
7 Employer's report of injury or occupational disease (PDF 296kb/2 pages)
Form 7 reference guide(PDF 78kb/3 pages) 		R06/08
7F Employer's report of injury or occupational disease — Fishing (PDF 263kb/2 pages) R06/08
9 Employer's statement of return to work (PDF 145kb/2 pages) R10/07
1800 Online WorkSafeBC registration  
1800 Employer's registration application (PDF 481kb/4 pages) R09/06
1801/1800 Personal Optional Protection insurance application package (PDF 663kb/8 pages) R12/08
1810 Guide to completing your Employer Payroll and Contract Labour Report (PDF 314kb/6 pages) R12/08
18E3 Application for alternative assessment procedure for interjurisdictional trucking (PDF 828kb/4 pages) R01/09
25M13 Request for disclosure (PDF 104kb/1 page) R07/07
30M33 Assurance of compliance with Occupational Health and Safety Regulation, part 19 (PDF 105kb/6 pages)
Sample only for viewing online. Forms are individually coded and can be ordered from WorkSafeBCStore.com		 R05/08
51M12 Request for extension to industrial audiometric technician authorization (PDF 95kb/1 page) R07/08
51M13 Application for authorization to conduct hearing tests under Occupational Health & Safety Regulation 7.8 (PDF 52kb/1page) 11/05
51M14 Order form for hearing loss prevention materials (PDF 107kb/1 page) R07/06
52E40 Incident investigation report (PDF 157kb/4 pages) R01/07
52E40F Fishing incident investigation report (PDF 315kb/3 pages) R05/07
  Notice of project online form  
52E48 Notice of project: Forestry, aircraft, diving, underground workings (PDF 59kb/1 page)
Sample only for viewing online. Forms are individually coded and can be ordered from WorkSafeBCStore.com. 		R01/06
52E49 Notice of project: Construction, asbestos, lead (PDF 127kb/1 page)
Sample only for viewing online. Forms are individually coded and can be ordered from WorkSafeBCStore.com. 		R08/08
55B23 First aid record (PDF 93kb/1 page) R02/08
55M7 Order for certification training materials - training agency use only (PDF 125kb/2 pages) R06/08
55M60 Occupational first aid patient assessment (PDF 46kb/1 page) R01/06
57M2 Material Safety Data Sheet - 9 sections (PDF 43kb/2 pages) R6/99
57M6 Material Safety Data Sheet - 16 sections (PDF 66kb/4 pages) R6/99
57M7 Discriminatory action - employer or union response (PDF 69kb/2 pages) 02/07
63M1 Request for review - Review Division (PDF 187kb/3 pages) R01/09
63M2 Notice to participate - Review Division (PDF 158kb/2 pages) R05/08
63M4 WorkSafeBC authorization of representative (PDF 119kb/1 page) R01/09
Form# Name Updated
3 Worker prescription claim (PDF 116kb/1 page)
Guidelines for completing reimbursement forms (PDF 20kb/1 page)		 R03/09
3A Worker supply and services claim (PDF 156kb/2 pages)
Guidelines for completing reimbursement forms (PDF 29kb/1 page) 		R11/08
68W41 2009 Worker Travel Reimbursment (PDF 181kb/1 pages)
CM054 Worker Travel Information Reimbursement (PDF 70kb/1 page)		 R04/09
4 Application for hearing loss resulting from exposure to long-term occupational noise (PDF 141kb/2 pages) R05/08
6 Worker's online incident and injury report  
6 Application for compensation and report of injury or occupational disease (PDF 340kb/3 pages)
Form 6 reference guide (PDF 86kb/5 pages) 		R07/08
6A Worker's report of injury or occupational disease to employer (PDF 177kb/2 pages) R06/08
6AB Asbestos-related disease - Application of worker (PDF 217kb/3 pages) R06/08
67W61 Asbestos-related disease - Election (Word 106kb/1 page) R10/08
6/7 Independent operator's application for compensation and report of injury or occupational disease (PDF 305kb/3 pages) R06/08
11M7 Request for access to records (PDF 53kb/1 page) R03/07
19W1 Direct deposit/address change (for monthly pension benefits) (MS Word 124kb/1 page) R01/08
19W153 Stop payment request (PDF 42kb/1 page) R03/08
25M13 Request for disclosure (PDF 104kb/1 page) R07/07
25W38 Forwarding form regarding eyeglasses (PDF 112kb/1 page) R09/07
25W40 Hearing loss and employment questionnaire (PDF 365kb/4 pages) R08/08
25W78 Appendix "B" - Personal injury claims election - Motor vehicle accident (PDF 87kb/1 page) R09/08
25W79 Appendix "A" - Personal injury claims election - Non-motor vehicle accident (PDF 69kb/1 page) R09/08
25W100 Request for income loss (PDF 48kb/1 page) R04/08
25W112 Change of name, address, or contact information (PDF 132kb/1 page) R02/08
57W1 Worker complaint of discriminatory action (PDF 209kb/9 pages) R01/08
57W2 Discriminatory action - worker election (PDF 51kb/1 page) 04/06
57W4 Discriminatory action - worker consent (PDF 44kb/1 page) 04/06
63M1 Request for review - Review Division (PDF 187kb/3 pages) R01/09
63M2 Notice to participate - Review Division (PDF 158kb/2 pages) R05/08
63M4 WorkSafeBC authorization of representative (PDF 119kb/1 page) R01/09
63M5 Review Division submission (PDF 145kb/2 pages)
Information sheet to 63M5 (PDF 78kb/1 page)		 08/04
65D53 Vocational Rehabilitation Services Third Party Agreement Invoice (PDF 89kb/2 page) R05/09
65W12 Vocational Rehabilitation Services Job Search Record Sheet (PDF 72kb/1 page) R10/07
66W5 Death information of pensioner/widow(er) (PDF 54kb/1 page) 10/03
68W32 Activity-related soft tissue disorder (ASTD) pre-site questionnaire (PDF 264kb/13 pages) R12/08
69W1 Worker's authorization for release of personal information (PDF 119kb/1 page) R01/08
Form# WorkSafeBC Designed Programs Updated
83D11 Activity-related soft tissue disorder (ASTD) services invoice (PDF 71kb/1 page) R06/09
83D12 Board-sponsored rehabilitation services fax cover sheet (PDF 105kb/1 page)
Board-sponsored rehabilitation services fax cover sheet (MS Word 105kb/1 page)		 R10/08
83D18 Head injury assessment and treatment services referral confirmation (PDF 61kb/1 page)
Head injury assessment and treatment services referral confirmation (MS Word 133kb/1 page)		 R11/08
83D21 Return to work support services referral confirmation (PDF 91kb/1 page) R10/08
83D22 Wound care and IV services invoice for WorkSafeBC (PDF 63kb/1 page) R11/08
83D23 Permanent functional impairment (PFI) referral confirmation (PDF 96kb/1 page)
Permanent functional impairment (PFI) referral confirmation (MS Word 114kb/1 page)		 R10/08
83D29 Hand program direct referral information sheet (PDF 77kb/1 page) R10/08
83D30 Program interrupt notification: Amputee Multidisciplinary Program (PDF 47kb/1 page) R09/08
83D31 Head injury assessment and treatment services (HIATS) invoice (PDF 66kb/1 page) R11/08
83D32 Medical and return-to-work planning (MARP) assessment services referral confirmation (PDF 102kb/1 page)
Medical and return-to-work planning (MARP) assessment services referral confirmation(MS Word 119kb/1 page)		 R12/08
83D33 Pre-approved adaptive aids (PDF 127kb/1 page) R10/08
83D36 Provider pre-authorized travel and expense confirmation (PDF 98kb/1 page) R10/08
83D37 Construction Safety Training System Invoice (PDF 39kb/1 page) R06/09
83D41 Sympathetically-mediated pain rehabilitation services (SPRS) invoice (PDF50kb/1 page) R11/08
83D42 Pain management program invoice (PDF 57kb/1 page) R06/09
83D138 Comprehensive multidisciplinary pain assessment invoice (PDF 62kb/1 page) R11/08
83D139 Return to work support services invoice (PDF 64kb/1 page)
Return to work support services invoice(MS Word 116kb/1 page)		 R11/08
83D140 Amputee multidisciplinary program invoice (PDF 60kb/1 page) R11/08
83D141 Functional capacity evaluation invoice (PDF 64kb/1 page) R11/08
83D142 Permanent functional impairment (PFI) assessment invoice (MS Word 191kb/1 page)
Permanent functional impairment (PFI) assessment invoice (PDF 60kb/1 page) 		R03/09
Form# Chiropractors Updated
8C/11C Chiropractor's report (120kb/2 pages) R10/08
11RC Chiropractor's x-ray report (PDF 130kb/2 pages) R11/07
267 Invoice for treatment services (PDF 77kb/1 page)
Invoice for treatment services(MS Word 117kb/1 page)		 R11/08
Form# Community Occupational Therapy Updated
83D24 Community occupational therapy initial assessment report and plan (PDF 139kb/2 pages) or
Community occupational therapy initial assessment report and plan (MS Word 137kb/2 pages)		 R09/08
83D25 Community occupational therapy file review report (PDF 290kb/2 pages)
Community occupational therapy file review report (MS Word 113kb/1 page)		 R09/08
83D26 Community occupational therapy invoice (PDF 242kb/2 pages)
Community occupational therapy invoice (MS Word 256kb/2 pages)		 R06/09
83D27 Community occupational therapy referral confirmation (PDF 47kb/1 page)
Community occupational therapy referral confirmation (MS Word 137kb/1 page)		 R09/08
83D36 Provider pre-authorized travel and expense confirmation (PDF 98kb/1 page) R10/08
83D43 Community occupational therapy progress report and plan (PDF 124kb/2 pages)
Community occupational therapy progress report and plan (MS Word140kb/2 pages)		 R09/08
83D44 Community occupational therapy discharge report (PDF 46kb/1 page)
Community occupational therapy discharge report (MS Word 122kb/1 page)		 R09/08
83M10 Vehicle modification assessment (PDF 973kb/7 pages) R10/08
83M102 Independence and home maintenance allowance referral (MS Word 96kb/2 pages) R09/08
Form# Dentists Updated
382 Dentist's report (PDF 123kb/2 pages) R09/08
Form# Diagnostic Imaging Updated
68D82 Surgical centre and diagnostic centre fax cover sheet (PDF 53kb/1 page)
Surgical centre and diagnostic centre fax cover sheet (WORD 113kb/1 page)		 R02/09
83D2 Diagnostic imaging requisition (PDF 109kb/1 page) R10/08
83D4 Request for magnetic resonance image (MRI) consultation (PDF 102kb/2 pages) R11/08
83D52 Expedited medical imaging facility invoice (PDF 117kb/1 page) 02/09
Form# Hearing Aid Program & Related Updated
51D3 Hearing aid battery invoice (PDF 96kb/1 page) R11/08
51D4 Audiological diagnostic report (MS Word 236kb/2 pages) R09/07
51M1 Employer authorization for submission of construction industry hearing test (PDF 45kb/1 page) R06/05
51M12 Request for extension to industrial audiometric technician authorization (PDF 95kb/1 page) R07/08
51M13 Application for authorization to conduct hearing tests under Occupational Health & Safety Regulation 7.8 (PDF 52kb/1page) 11/05
51W6 Hearing aid replacement information (PDF124kb/1 page) R03/08
51W12 Hearing aid provision and services invoice (PDF 132kb/1 page) R11/08
83D110 Hearing Aid Program cover sheet (PDF 36kb/1 page) R06/09
83D112 Tinnitus Retraining Therapy (TRT) report (MS Word 241kb/2 pages) R09/08
Form# Home Care Services Updated
83M11 Home care services referral confirmation (PDF 242kb/1 page)
Home care services referral confirmation (MS Word 151kb/1 page)		 R09/08
83M12 Home care services assessment (PDF 551kb/6 pages)
Home care services assessment (MS Word 278kb/5 pages)		 R09/08
83M13 Home care services care plan (PDF 377kb/3 pages)
Home care services care plan (MS Word 180kb/3 pages)		 R09/08
83M14 Home care services invoice (PDF 108kb/1 page)
Home care services invoice (MS Word 210kb/1 page)		 R11/08
83M15 Home care services progress/discharge report (PDF 317kb/2 pages)
Home care services progress/discharge report (MS Word 138kb/1 page)		 R09/08
Form# Hospital Updated
11H Hospital account (PDF 159kb/1 page) R11/08
Form# Mental Health Treatment & Assessment Updated
10D4 Invoice for psychology services (PDF 79kb/1 page)
Invoice for psychology services (MS Word 230kb/1 page)		 R11/08
10D5 Psychology assessment report (MS Word 221kb/1 page) R09/08
10D6 Mental health treatment report (MS Word 230kb/2 pages) R09/08
Form# Naturopathic Physicians Updated
8N Naturopathic physician's first report (PDF 200kb/2 pages) R12/08
11AN Naturopathic physician's invoice (PDF 66kb/1 page) R11/08
11N Naturopathic physician's progress/final report (PDF 184kb/2 pages) R12/08
Form# Optical/Optometry Updated
25W38 Forwarding form regarding eyeglasses (PDF 112kb/1 page) R09/07
Form# Orthotic & Prosthetic Services Updated
83D13 Invoice for prosthetic services (PDF 80kb/1 page) R06/09
83D16 Invoice for orthotic services (PDF 63kb/1 page) R06/09
83D19 Request for authorization for prosthetic services (PDF 171kb/2 pages) R09/08
83D20 Request for authorization for orthotic services (PDF 116kb/1 page) R09/08
Form# Physicians & Surgical Facilities Updated
8/11 Physician's report (PDF 114kb/2 pages)
Physician reference guide (PDF 159kb/23 pages)		 R10/08
8/11 Addendum Practitioner's report / Additional information (PDF 93kb/2 pages) R12/08
11A Physician's invoice (PDF 135kb/1 page) R11/08
68D82 Surgical centre and diagnostic centre fax cover sheet (PDF 53kb/1 page)
Surgical centre and diagnostic centre fax cover sheet (WORD 113kb/1 page)		 R02/09
83D2 Diagnostic imaging requisition (PDF 109kb/1 page) R10/08
83D3 WorkSafeBC nerve blocks (PDF 140kb/2 pages) R10/08
83D4 Request for magnetic resonance image (MRI) consultation (PDF 102kb/2 pages) R11/08
83D5 Surgical facility invoice (PDF 122kb/1 page)
Surgical facility invoice (MS Word 161kb/1 page)		 R11/08
83D6 Authorization request for expedited surgery (PDF 53kb/1 page) R09/04
83D8 Summary invoice for expedited surgery (PDF 61kb/1 page)
Summary invoice for expedited surgery (MS Word 112kb/1 page)		 R05/09
83D9 Summary invoice for assist (PDF 44kb/1 page)
Summary invoice for assist (MS Word 102kb/1 page)		 R05/09
83D10 Summary invoice for anesthesia (PDF 100kb/1 page)
Summary invoice for anesthesia (MS Word 166kb/1 page)		 R06/09
83D40 Visiting Specialist Clinic sessional detail invoice (PDF 50kb/1 page)
Visiting Specialist Clinic sessional detail invoice (MS Word 135kb/1 page)		 R06/09
83D52 Expedited medical imaging facility invoice (PDF 117kb/1 page) 02/09
83D53 Surgical facility pre-authorized expense confirmation (PDF 47kb/1 page)
Surgical facility pre-authorized expense confirmation (MS Word 125kb/1 page)		 R03/09
83D135 Neuropsychiatry assessment and treatment fax cover sheet (PDF 79kb/1 page) 10/08
83M1 Pre-operative assessment (PDF 52kb/2 pages) R09/08
Form# Physiotherapy Updated
83W5 Physiotherapy initial notification (PDF 91kb/1 page) R10/08
267 Invoice for treatment services (PDF 77kb/1 page)
Invoice for treatment services(MS Word 117kb/1 page)		 R11/08
268 Physiotherapy report (PDF 144kb/3 pages)
Physiotherapy report (MS Word 251 kb/2 pages)		 R09/08
Form# Registered Massage Therapists Updated
267 Invoice for treatment services (PDF 77kb/1 page)
Invoice for treatment services(MS Word 117kb/1 page)		 R11/08
Form# Residential Care Services Updated
83D34 Residential Care Services monthly update (PDF 377kb/3 pages) or
Residential Care Services monthly update (MS Word 269kb/3 pages)		 R09/08
83D102 Residential Care Services clinical care plan (PDF 177kb/3 pages)
Residential Care Services clinical care plan (MS Word 182kb/3 pages)		 R10/08
83D103 Residential Care Services invoice (PDF 116kb/1 page) R11/08
Form# Self-managed Care Services Updated
83M108 Self-managed care - care plan cost (PDF 65kb/1 page)
Self-managed care - care plan cost (MS Word 165kb/1 page)		 R09/08
83W6 Self-managed care (SMC) monthly reconciliation report (PDF 114kb/1 page) 09/08
83W133 Self-managed care quarterly update (MS Word 190kb/3 pages) R01/08
83W134 Self-managed care invoice (PDF 95kb/1 page) R11/08
Form# General Updated
25M95 Personal Care Allowance Assessment (MS Word 307kb/7 pages) R03/08
19D1 Direct Deposit in Canada - Provider (PDF 50kb/1 page)
Direct Deposit in Canada - Provider (MS Word 112kb/1 page)		 R04/09
51M14 Order form for hearing loss prevention materials (PDF 107kb/1 page) R07/06
83D38 Complex medication consultation fax cover sheet (PDF 58kb/1 page) R10/08
83D51 Generic Report - Medical and Health Care (PDF 177kb/1 page)
Generic Report - Medical and Health Care (MS Word 109kb/1 page)		 09/08
83D128 Generic Invoice - Medical and Health Care (PDF 116kb/1 page)
Generic Invoice - Medical and Health Care (MS Word 165kb/1 page)		 R11/08
83D132 Residential addiction services fax cover sheet (PDF 77kb/1 page) R10/08
Form# Name Updated
65D2 Vocational Rehabilitation Services external provider network service invoice (PDF 129kb/2 pages) R10/08
65D28 Vocational Rehabilitation Servics vocational interest and aptitude testing final report (Word 157kb/3 pages) R09/08
65D29 Vocational Rehabilitation Services supported job placement follow-up report (Word 172kb/3 pages) R09/08
65D30 Vocational Rehabilitation Services supported job placement monthly report
(Word 133kb/2 pages)		 R09/08
65D31 Vocational Rehabilitation Services supported job placement report (Word 158kb/3 pages) R09/08
65D32 Vocational Rehabilitation Services supported job placement intake report: Action plan (Word 155kb/3 pages) R09/08
65D33 Vocational Rehabilitation Services job-finding club intake report (Word 127kb/2 pages) R09/08
65D34 Vocational Rehabilitation Services job-finding club final report
(Word 183kb/4 pages)		 R09/08
65D35 Vocational Rehabilitation Services individualized job placement report (Word 157kb/2 pages) R09/08
65D36 Vocational Rehabilitation Services individualized job placement intake report: Action plan (Word 155kb/3 pages) R09/08
65D37 Vocational Rehabilitation Services individualized job placement monthly report
(Word 143kb/2 pages)		 R09/08
65D38 Vocational Rehabilitation Services individualized job placement follow-up report
(Word 172kb/3 pages)		 R09/08
65D39 Vocational Rehabilitation Services job-search skills final report (Word 143kb/2 pages) R09/08
65D40 Vocational Rehabilitation Services psycho-vocational testing/assessment final report
(Word 159kb/3 pages)		 R09/08
65D41 Vocational Rehabilitation Services resume and cover letter preparation final report (Word 134kb/2 pages) R09/08
65D52 Vocational Rehabilitation Services business start-up/enhancement service invoice
(PDF 105kb/2 pages)		 R10/08
65D53 Vocational Rehabilitation Services third party agreement invoice
(PDF95kb/2 pages)		 R05/09
65D55 Vocational Rehabilitation Services third party agreement report cover sheet
(Word 123kb/1 page)		 R09/08
65D56 Vocational Rehabilitation Services business start-up/enhancement report cover sheet (Word 123kb/1 page) R09/08
19D1 Direct Deposit in Canada - Provider (PDF 50kb/1 page)
Direct Deposit in Canada - Provider (MS Word 112kb/1 page)		 R04/09