COVID-19 Initial Screening Questionnaire (Form 65W122)

To accept a claim for COVID-19, WorkSafeBC must have evidence that it was contracted as a direct result of your employment. We will review all COVID-19 claims on a case-by-case basis, considering the individual facts and circumstances.

If you’re a worker who is submitting a claim for a COVID-19 infection contracted through a work-related exposure, you must first report your injury or disease to us to start a claim. If the claim has been started, either by yourself or your employer and you have a claim number, please proceed to complete and submit the questionnaire.

In order to consider whether your illness is work related, we may need to gather additional information through our COVID-19 Initial Screening Questionnaire.

Want to submit your form online?

  1. Once you have a claim number for your claim, download and complete the fillable PDF in Acrobat Reader (a free application), and save it. Alternatively, you can print the form, fill it out manually, and scan and save it.
  2. Submit it to us by selecting Upload form and following the instructions. This tool will add the form directly to your claim file.

For more information, including instructions on how to add your electronic signature, see Complete & submit fillable PDF forms online.

Need help?

If you are unable to submit your questionnaire, please call our Claims Call Centre for assistance. If you need technical help, please contact our Technical Support team.

For more information

For more information on how we adjudicate COVID-19 claims, please see our COVID-19 claims Information for workers.

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Publication Date: Dec 2022 File type: PDF (358 KB) Asset type: Form Form: 65W122