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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.

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WorkSafeBC Forms

Form# Name Date
6/7 Independent operator's application for compensation and report of injury or occupational disease
(PDF 76kb/2 pages) 		R03/06
7 Online incident and injury report  
7 Employer's report of injury or occupational exposure
(PDF 270kb/2 pages) 		R01/08
7A The First aid report form is no longer in use. The information on it has been consolidated into the online and paper versions of Form 7. Find out more.  
7F Employer's report of injury or occupational disease — Fishing
(PDF 106kb/2 pages) 		02/05
9 Employer's statement of return to work
(fillable PDF 113kb/2 pages) 		R03/06
1800 Online WorkSafeBC registration R04/04
1800 Employer's registration application
(PDF 481kb/4 pages) 		R09/06
1801/1800 Personal Optional Protection insurance application package
(PDF 6.3mb/8 pages) 		R01/08
1810 Guide to completing your Employer Payroll and Contract Labour Report
(PDF 547kb/6 pages) 		R12/07
18E3 Application for alternative assessment procedure for interjurisdictional trucking
(PDF 247kb/4 pages) 		R06/08
25M13 Request for disclosure
(fillable 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 fromWorkSafeBCStore.com		 R05/08
51M12 Request for extension to industrial audiometric technician authorization
(fillable 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
(fillable 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
52E48 Notice of project online form  
  Notice of project: Forestry, aircraft, diving, underground workings
(PDF 59kb/1 pages)
Sample only for viewing online. Forms are individually coded and can be ordered from WorkSafeBCStore.com. 		R01/06
52E49 Notice of project online form  
  Notice of project: Construction, asbestos, lead
(PDF 88kb/2 pages)
Sample only for viewing online. Forms are individually coded and can be ordered from WorkSafeBCStore.com. 		R11/05
55B23 First aid record
(fillable PDF 93kb/1 page) 		R02/08
55M7 Order for certification training materials - training agency use only
(fillable 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
(fillable PDF 150kb/3 pages) 		R03/07
63M2 Notice to participate
(fillable PDF 78kb/2 pages) 		01/03
63M4 WCB authorization of representative
(fillable PDF 207kb/1 page) 		08/04
6A Worker's report of injury or occupational disease to employer
(PDF 81kb/2 pages)
(Provided here so employers can give to workers.)		 R04/05
Form# Name Date
3 Worker prescription claim
(fillable PDF 116kb/1 page)
Guidelines for completing reimbursement forms
(PDF 20kb/1 page)		 R07/08
3A Worker supply and services claim
(fillable PDF 156kb/2 pages)
Guidelines for completing reimbursement forms
(PDF 20kb/1 page)		 07/08
4 Application for hearing loss resulting from exposure to long-term occupational noise
(fillable PDF 112kb/2 pages) 		R03/06
6 Application for compensation and report of injury or occupational disease
(fillable PDF 149kb/2 pages) 		R03/06
6A Worker's report of injury or occupational disease to employer
(PDF 81kb/2 pages) 		R04/05
6AB Application of worker - asbestos-related disease
(PDF 153kb/4 pages) 		R01/04
6/7 Independent operator's application for compensation and report of injury or occupational disease
(PDF 76kb/2 pages) 		R03/06
11M7 Request for access to records
(PDF 53kb/1 page) 		R03/07
19W1 Direct deposit/address change (for monthly pension benefits)
(PDF 77kb/1 page) 		R10/06
19W153 Stop payment request
(PDF 42kb/1 page)
R10/04
25M13 Request for disclosure
(fillable PDF 104kb/1 page) 		R07/07
25W40 Hearing loss and employment questionnaire
(PDF 103kb/4 pages) 		R03/06
25W78 Appendix "B" - Motor vehicle accident
(fillable PDF 84kb/1 page) 		R10/07
25W79 Appendix "A" - Non-motor vehicle accident
(fillable PDF 67kb/1 page) 		R10/07
25W100 Request for income loss
(PDF 96kb/1 page) 		04/07
25W112 Change of name, address, or contact information
(PDF 89kb/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
(fillable PDF 197kb/3 pages) 		R05/08
63M2 Notice to participate - Review Division
(fillable PDF 158kb/2 pages) 		R05/08
63M4 WorkSafeBC authorization of representative
(fillable PDF 126kb/1 page) 		R10/07
63M5 Review Division submission
(PDF 145kb/2 pages)
Information sheet to 63M5
(PDF 78kb/1 page) 		08/04
66W5 Death information of pensioner/widow(er)
(PDF 54kb/1 page) 		10/03
69W1 Worker's authorization for release of personal information
(fillable PDF 119kb/1 page)		 R01/08
Form# Name Date
8/11 Physician's report
(fillable PDF 117kb/2 pages)
Quick reference guide
(PDF 150kb/22 pages) 		R03/06
8/11 Addendum Practitioner's report / Additional information
(PDF 64kb/2 pages) 		R08/03
8C/11C Chiropractor's report
(fillable PDF 121kb/2 pages)		 R03/06
8N Naturopathic physician's first report
(fillable PDF 202kb/2 pages) 		R05/08
11A Physician's invoice
(fillable PDF 134kb/1 page) 		R12/07
11AN Naturopathic physician's invoice
(fillable PDF 139kb/1 page) 		R02/08
11H Hospital account
(fillable PDF 159kb/1 page) 		R05/08
11N Naturopathic physician's progress/final report
(fillable PDF 184kb/2 pages) 		R05/08
11RC Chiropractor's x-ray report
(PDF 130kb/2 pages) 		R11/07
267 Invoice for treatment services
(fillable PDF 162kb/1 page) 		R01/08
268 Physiotherapy report
(fillable PDF 142kb/3 pages) or (fillable MS Word 251 kb/2 pages)		 R10/07
382 Dentist's report
(PDF 123kb/2 pages) 		R05/08
10D4 Invoice for psychology services
(fillable PDF 162kb/1 page) or (fillable MS Word 229kb/1 page) 		R05/08
10D5 Psychology assessment report
(fillable MS Word 221kb/1 page) 		R09/07
10D6 Mental health treatment report
(fillable MS Word 228kb/2 pages) 		R09/07
25W38 Forwarding form regarding eyeglasses
(PDF 53kb/1 page) 		R06/04
51D3 Hearing aid battery invoice
(fillable PDF 99kb/1 page) 		R01/08
51D4 Audiological diagnostic report
(fillable 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
(fillable 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
(fillable PDF 107kb/1 page)		 R07/06
51W6 Hearing aid replacement information
(fillable PDF 92kb/1 page) 		R03/08
51W12 Hearing aid provision and services invoice
(fillable PDF 132kb/1 page) 		R06/08
83B100 Memo to diagnostic imaging records
(fillable PDF 93kb/1 page) 		R11/04
83D2 Diagnostic imaging requisition
(fillable PDF 109kb/1 page) 		R04/08
83D3 WorkSafeBC nerve blocks
(fillable PDF 139kb/2 pages) 		R05/08
83D4 Request for magnetic resonance image (MRI) consultation
(fillable PDF 83kb/2 pages) 		R10/07
83D5 Surgical facility invoice
(fillable PDF 127kb/1 page) 		R11/07
83D6 Authorization request for expedited surgery
(PDF 53kb/1 page) 		R09/04
83D8 Summary invoice for expedited surgery
(fillable PDF 58kb/1 page) 		R12/07
83D9 Summary invoice for assist
(fillable PDF 46kb/1 page) 		R12/07
83D10 Summary invoice for anesthesia
(fillable PDF 138kb/1 page) 		R12/07
83D11 Activity-related soft tissue disorder (ASTD) services invoice
(fillable PDF 68kb/1 page) 		R12/07
83D12 Board-sponsored rehabilitation services fax cover sheet
(fillable PDF 485kb/1 page) 		R10/07
83D13 Invoice for prosthetic services
(fillable PDF 155kb/1 page) 		R01/08
83D16 Invoice for orthotic services
(fillable PDF 63kb/1 page) 		R01/08
83D18 Head injury assessment and treatment services referral confirmation
(fillable PDF 60kb/1 page) 		R05/08
83D19 Request for authorization for prosthetic services
(fillable PDF 169kb/2 pages) 		R04/08
83D20 Request for authorization for orthotic services
(fillable PDF 116kb/1 page) 		R03/08
83D21 Return to work support services referral confirmation
(fillable PDF 90kb/1 page)
 R12/07
83D22 Wound care and IV services invoice for WorkSafeBC
(fillable PDF 136kb/1 page) 		R02/08
83D23 Permanent functional impairment (PFI) referral confirmation
(fillable PDF 96kb/1 page) 		R04/08
83D24 Community occupational therapy initial assessment report and plan
(fillable PDF 131kb/2 pages) or (fillable MS Word 136kb/2 pages) 		R04/08
83D25 Community occupational therapy file review report
(fillable PDF 286kb/2 pages) or (fillable MS Word 113kb/1 page) 		R04/08
83D26 Community occupational therapy invoice
(fillable PDF 161kb/2 pages) 		R03/08
83D27 Community occupational therapy referral confirmation
(fillable PDF 43kb/1 page) or (fillable MS Word 136kb/1 page)		 R04/08
83D29 Hand program direct referral information sheet
(fillable PDF 77kb/1 page)		 R02/08
83D30 Program interrupt notification: Amputee Multidisciplinary Program
(fillable PDF 43kb/1 page)		 R05/08
83D31 Head injury assessment and treatment services (HIATS) invoice
(fillable PDF 153kb/1 page) 		R05/08
83D32 Medical and return-to-work planning (MARP) assessment services referral confirmation
(fillable PDF 102kb/1 page) or (fillable MS Word 119kb/1 page)		 R03/08
83D33 Pre-approved adaptive aids
(fillable PDF 127kb/1 page) 		R04/08
83D34 Residential Care Services monthly update
(fillable PDF 333kb/3 pages) or (fillable MS Word 269kb/3 pages)		 04/08
83D36 Provider pre-authorized travel and expense confirmation
(fillable PDF 98kb/1 page) 		11/07
83D37 Construction Safety Training System Invoice
(fillable PDF 42kb/1 page) 		R11/07
83D38 Complex medication consultation fax cover sheet
(fillable PDF 58kb/1 page) 		R10/07
83D41 Sympathetically-mediated pain rehabilitation services (SPRS) invoice
(fillable PDF 63kb/1 page) 		R11/07
83D42 Pain management program invoice
(fillable PDF 69kb/1 page) 		R11/07
83D43 Community occupational therapy progress report and plan
(fillable PDF 121kb/2 pages) or (fillable MS Word 140kb/2 pages) 		R05/08
83D44 Community occupational therapy discharge report
(fillable PDF 43kb/1 page) or (fillable MS Word 122kb/1 page) 		R05/08
83D51 Generic Report - Medical and Health Care
(fillable PDF 173kb/1 page) 		03/08
83D102 Residential Care Services clinical care plan
(fillable PDF 177kb/3 pages) or (fillable MS Word 181kb/3 pages)		 04/08
83D103 Residential Care Services invoice
(fillable PDF 123kb/1 page) 		12/07
83D110 Hearing Aid Program cover sheet
(PDF 83kb/1 page) 		02/08
83D112 Tinnitus Retraining Therapy (TRT) report
(fillable MS Word 241kb/2 page) 		09/07
83D128 Generic Invoice - Medical and Health Care
(fillable PDF 116kb/1 page) 		11/07
83D132 Residential addiction services fax cover sheet
(fillable PDF 77kb/1 page) 		01/08
83D138 Comprehensive multidisciplinary pain assessment invoice
(fillable PDF 63kb/1 page) 		R04/08
83D139 Return to work support services invoice
(fillable PDF 64kb/1 page) 		R04/08
83D140 Amputee multidisciplinary program invoice
(fillable PDF 61kb/1 page) 		R04/08
83D141 Functional capacity evaluation invoice
(fillable PDF 64kb/1 page) 		R04/08
83D142 Permanent functional impairment (PFI) assessment invoice
(fillable PDF 60kb/1 page) 		R04/08
83M1 Pre-operative assessment
(PDF 52kb/2 pages)		 10/07
83M10 Vehicle modification assessment
(fillable PDF 1.0mb/7 pages)		 05/08
83M11 Home care services referral confirmation
(fillable PDF 238kb/1 page) or (fillable MS Word 151kb/1 page)		 03/08
83M12 Home care services assessment
(fillable PDF 505kb/6 pages) or (fillable MS Word 279kb/5 pages)		 04/08
83M13 Home care services care plan
(fillable PDF 373kb/3 pages) or (fillable MS Word 180kb/3 pages)		 03/08
83M14 Home care services invoice
(fillable PDF 223kb/1 page) or (fillable MS Word 211kb/1 page)		 03/08
83M15 Home care services progress/discharge report
(fillable PDF 313kb/2 pages) or (fillable MS Word 185kb/1 page)		 03/08
83M102 Independence and home maintenance allowance referral
(fillable MS Word 96kb/2 pages) 		R04/08
83M108 Self-managed care - care plan cost
(fillable PDF 62kb/1 page) or (fillable MS Word 166kb/1 page) 		03/08
83W5 Physiotherapy initial notification
(fillable PDF 91kb/1 page) 		R04/08
83W6 Self-managed care (SMC) monthly reconciliation report
(fillable PDF 114kb/1 page) 		04/08
83W133 Self-managed care quarterly update
(fillable MS Word 190kb/3 pages) 		01/08
83W134 Self-managed care invoice
(fillable PDF 95kb/1 page) 		03/08
Form# Name Date
65D2 Vocational Rehabilitation Services external provider network service invoice
(fillable PDF 128kb/2 pages)
R05/08
65D28 Vocational Rehabilitation Servics vocational interest and aptitude testing final report
(fillable Word 156kb/3 pages)
R10/07
65D29 Vocational Rehabilitation Services supported job placement follow-up report
(fillable Word 172kb/3 pages)
R10/07
65D30 Vocational Rehabilitation Services supported job placement monthly report
(fillable Word 133kb/2 pages) 		R10/07
65D31 Vocational Rehabilitation Services supported job placement report
(fillable Word 158kb/3 pages) 		R10/07
65D32 Vocational Rehabilitation Services supported job placement intake report: Action plan
(fillable Word 155kb/3 pages)
R10/07
65D33 Vocational Rehabilitation Services job-finding club intake report
(fillable Word 127kb/2 pages)
R10/07
65D34 Vocational Rehabilitation Services job-finding club final report
(fillable Word 182kb/4 pages) 		R10/07
65D35 Vocational Rehabilitation Services individualized job placement report
(fillable Word 157kb/2 pages)
R10/07
65D36 Vocational Rehabilitation Services individualized job placement intake report: Action plan
(fillable Word 155kb/3 pages) 		R10/07
65D37 Vocational Rehabilitation Services individualized job placement monthly report
(fillable Word 143kb/2 pages)
R10/07
65D38 Vocational Rehabilitation Services individualized job placement follow-up report
(fillable Word 172kb/3 pages) 		R10/07
65D39 Vocational Rehabilitation Services job-search skills final report
(fillable Word 143kb/2 pages) 		R10/07
65D40 Vocational Rehabilitation Services psycho-vocational testing/assessment final report
(fillable Word 159kb/3 pages)
R10/07
65D41 Vocational Rehabilitation Services resume and cover letter preparation final report
(fillable Word 134kb/2 pages) 		R10/07
65D52 Vocational Rehabilitation Services business start-up/enhancement service invoice
(fillable PDF 113kb/2 pages) 		03/08
65D53 Vocational Rehabilitation Services third party agreement invoice
(fillable PDF 87kb/2 pages) 		R05/08
65D55 Vocational Rehabilitation Services third party agreement report cover sheet
(fillable Word 122kb/1 page) 		R05/08
65D56 Vocational Rehabilitation Services business start-up/enhancement report cover sheet
(fillable Word 122kb/1 page)
R05/08