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Get Canada WSIB 0041A 2007-2024

Home Help/Tips Mail To home 200 Front Street West Toronto ON M5V 3J1 print OR Fax To Print 416-344-4684 OR 1-888-313-7373 reset Worker s Progress Report Form 41 Desk No. Alloc. No. Claim Number Reset Please PRINT in black ink Worker s Name Reset this Original Reset ThisAccident/Injury Date of Accident Employer Name Injury Page page If any information is incorrect please provide the changes here 1. Please check which status best describes your current condition Recovered Getting Better No Change Getting Worse Describe any details or changes to your condition 2. Who is the primary health professional directing your current treatment last visit 3. Please specify any referrals you have not yet reported to the WSIB no new referrals testing e.g. labs x-rays CT Scan MRI etc. Name/Facility dd specialist mm yy next visit other specify 4. Home Help/Tips Mail To home 200 Front Street West Toronto ON M5V 3J1 print OR Fax To Print 416-344-4684 OR 1-888-313-7373 reset Worker s Progress Report Form 41 Desk No* Alloc* No* Claim Number Reset Please PRINT in black ink Worker s Name Reset this Original Reset ThisAccident/Injury Date of Accident Employer Name Injury Page page If any information is incorrect please provide the changes here 1. Please check which status best describes your current condition Recovered Getting Better No Change Getting Worse Describe any details or changes to your condition 2. Who is the primary health professional directing your current treatment last visit 3. Please specify any referrals you have not yet reported to the WSIB no new referrals testing e*g* labs x-rays CT Scan MRI etc* Name/Facility dd specialist mm yy next visit other specify 4. Are you presently taking any drugs/medications or using an assistive device/brace for this injury If yes list names Date of that appointment no yes 5. Have you worked for any employer s or were you self employed between the first day off and now If yes provide details including dates name/address of employer/company 6. Choose one of the following that best describes your current situation* For this claim I have not lost any time or pay from work complete only question 7 I have lost time and/or pay and have returned to work complete only questions 7 and 8 7. Was your return a regular work OR modified work to work to b regular pay OR lower pay less hours c regular hours OR 9. Have you talked to your health professional about return to work If yes date of last discussion and have they determined your work limitations or functional abilities 11. Has any type of work been offered to you 8. Date of your return to work name of person you talked to 12. Are there any other factors that are preventing you from returning to work It is an offence to deliberately make false statements to the Workplace Safety and Insurance Board. I declare that all of the help/tips information provided on this page is true. Date dd/mm/yy Signature Please print form sign before returning to the WSIB Home 0041A 08/07. Home Help/Tips Mail To home 200 Front Street West Toronto ON M5V 3J1 print OR Fax To Print 416-344-4684 OR 1-888-313-7373 reset Worker s Progress Report Form 41 Desk No* Alloc* No* Claim Number Reset Please PRINT in black ink Worker s Name Reset this Original Reset ThisAccident/Injury Date of Accident Employer Name Injury Page page If any information is incorrect please provide the changes here 1. Please check which status best describes your current condition Recovered Getting Better No Change Getting Worse Describe any details or changes to your condition 2. .

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