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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) 		R02/11
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 337kb/4 pages) R09/10
1801/1800 Personal Optional Protection insurance application package (PDF 401kb/8 pages) R01/12-
12/12
1810 Guide to completing your Employer Payroll and Contract Labour Report (PDF 1mb/6 pages) R01/12
18E3 Application for alternative assessment procedure for interjurisdictional trucking (PDF 210kb/4 pages) R10/10
18E17 Voluntary coverage application (PDF 366kb/5 pages) R05/11
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
50D7 Application for registration as first aid training agency (PDF 111kb/1 page) 03/12
50M5 Application for Course Review (Word 123kb/2 pages) R04/12
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 102kb/1page) R11/11
51M14 Order form for hearing loss prevention materials (PDF 81kb/1 page) R06/10
52E40 Incident investigation report (PDF 157kb/4 pages) R01/07
52E40F Fishing incident investigation report (PDF 212kb/3 pages) R06/11
  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 or submit it online. 		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 or submit it online. 		R08/08
55B23 First aid record (PDF 97kb/1 page) R03/08
55M7 Order for certification training materials - training agency use only (PDF 130kb/2 pages) R06/10
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 83kb/2 pages) R08/10
63M1 Request for review - Review Division (PDF 187kb/3 pages) R08/11
63M2 Notice to participate - Review Division (PDF 158kb/2 pages) R05/08
63M4 WorkSafeBC authorization of representative (PDF 109kb/1 page) R07/11
68E11 Request for S.30/vocational rehabilitation earnings from employer - G (PDF 143kb/1 page) R08/11
68E23 Employer's report of worker's employment — hearing loss (PDF 111kb/1 page) R07/10
Form# Name Updated
3 Worker prescription claim (PDF 142kb/1 page)
Worker prescription claim (Word 150kb/1 page)
Guidelines for completing reimbursement forms (PDF 20kb/1 page)		 R04/11
3A Worker supply and services claim (PDF 176kb/2 pages)
Worker supply and services claim (Word 190kb/2 pages)
Guidelines for completing reimbursement forms (PDF 29kb/1 page) 		R04/12
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 247kb/3 pages)
Form 6 reference guide (PDF 89kb/5 pages) 		R01/12
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 Request for direct deposit in Canada (PDF 140kb/1 page)
Request for direct deposit in Canada (MS Word 125kb/1 page)		 R02/11
19W153 Stop payment request (PDF 42kb/1 page) R01/12
25M13 Request for disclosure (PDF 121kb/1 page) R05/10
25W38 Forwarding form regarding eyeglasses (PDF 97kb/1 page) R09/07
25W40 Hearing loss and employment questionnaire (PDF 283kb/4 pages) R11/11
25W78 Election to claim compensation (PDF 177kb/2 pages)
Election to claim compensation (MS Word 136kb/2 pages)		 R01/11
25W79 Election to claim compensation - Fatal claim (PDF 229kb/2 pages)
Election to claim compensation - Fatal claim (MS Word 137kb/2 pages)		 R09/10
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 193kb/9 pages) R09/09
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) R08/11
63M2 Notice to participate - Review Division (PDF 158kb/2 pages) R05/08
63M4 WorkSafeBC authorization of representative (PDF 109kb/1 page) R07/11
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
68W32 Activity-related soft tissue disorder (ASTD) pre-site questionnaire (PDF 337kb/13 pages)
Activity-related soft tissue disorder (ASTD) pre-site questionnaire (MS Word 500kb/5 pages)		 R02/11
69W1 Worker's authorization for release of personal information (PDF 119kb/1 page) R01/08
Form# WorkSafeBC Designed Programs Updated
68M63 Activity-Related Soft Tissue Disorder (ASTD) Worksite Evaluation Report (MS Word 221kb/5 pages) R10/10
83D12 Board-sponsored rehabilitation services fax cover sheet (PDF 94kb/1 page)
Board-sponsored rehabilitation services fax cover sheet (MS Word 136kb/1 page)		 R08/11
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 111kb/1 page) R04/10
83D142 Permanent functional impairment (PFI) assessment invoice (MS Word 189kb/1 page)
Permanent functional impairment (PFI) assessment invoice (PDF 103kb/1 page) 		R04/10
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
83D62 Extension of chiropractic treatment request - Extenuating circumstances (PDF 173kb/2 pages) 10/10
267 Invoice for treatment services (PDF 77kb/1 page)
Invoice for treatment services(MS Word 117kb/1 page)		 R09/09
Form# Community Brain Injury Services Updated
83D36 Provider pre-authorized travel and expense confirmation (PDF 98kb/1 page) R10/08
83D51 Generic Report - Medical and Health Care (PDF 46kb/1 page)
Generic Report - Medical and Health Care (MS Word 110kb/1 page)		 R08/09
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
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 972kb/7 pages) R06/09
83M102 Independence and home maintenance allowance (MS Word 96kb/2 pages) R03/09
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 55kb/1 page)
Surgical centre and diagnostic centre fax cover sheet (WORD 114kb/1 page)		 R10/09
83D5 Surgical facility or medical imaging facility invoice (PDF 187kb/1 page)
Surgical facility or medical imaging facility invoice (MS Word 162kb/1 page)		 R05/10
83D56 Requisition for medical imaging (PDF 197kb/2 pages)
Requisition for medical imaging (MS Word 144kb/2 pages)		 R02/12
83D58 Requisition for expedited diagnostic and therapeutic injections (PDF 231kb/2 pages)
Requisition for expedited diagnostic and therapeutic injections (MS Word 139kb/2 pages)		 12/09
83D63 Requisition for Electrodiagnostic Studies (PDF 165kb/1 page)
Requisition for Electrodiagnostic Studies (MS Word 139kb/1 page)		 R04/12
Form# Hearing Aid Program & Related Updated
51D3 Hearing aid battery invoice (PDF 122kb/1 page)
Hearing aid battery invoice (MS Word 159kb/1 page)		 R05/10
51D4 Audiological Diagnostic Assessment (MS Word 236kb/2 pages) R09/11
51D12 Hearing aid provision and services invoice (PDF 229kb/1 page)
Hearing aid provision and services invoice (MS Word 195kb/1 page)		 R10/11
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 102kb/1page) R11/11
51W6 Hearing aid replacement information (PDF 167kb/2 pages)
Hearing aid replacement information (MS Word 147kb/2 pages)		 R09/11
69D9 Hearing Aid Provider Serial Number Record (PDF 130kb/1 page)
Hearing Aid Provider Serial Number Record (MS Word 147kb/1 page)		 09/11
83D110 Hearing Aid Program cover sheet (PDF 110kb/1 page) R08/10
83D112 Tinnitus Retraining Therapy (TRT) report (MS Word 120kb/2 pages) R05/12
Form# Home Care Services Updated
83M11 Home care services referral confirmation (PDF 86kb/1 page)
Home care services referral confirmation (MS Word 143kb/1 page)		 R05/09
83M12 Home Care Assessment and Care Plan (PDF348kb/6 pages)
Home Care Assessment and Care Plan (MS Word 191kb/5 pages)		 R03/11
83M14 Home care services invoice (PDF 154kb/1 page)
Home care services invoice (MS Word 208kb/1 page)		 R04/10
83M15 Home care services progress/discharge report (PDF122kb/2 pages)
Home care services progress/discharge report (MS Word 134kb/1 page)		 R03/11
Form# Hospital Updated
11H Hospital account (PDF 159kb/1 page) R11/08
Form# Mental Health Treatment & Assessment Updated
10D4 Invoice for psychology services (PDF 139kb/1 page)
Invoice for psychology services (MS Word 162kb/1 page)		 R07/10
10D5 Psychology assessment report (PDF 124kb/1 page)
Psychology assessment report (MS Word 113kb/1 page)		 R03/11
10D6 Mental health treatment report (PDF 260kb/5 pages)
Mental health treatment report (MS Word 160kb/4 pages)		 R05/12
10D81 Psychology - File Review Report (MS Word 120kb/1 page) 03/11
Form# Naturopathic Physicians Updated
8N Naturopathic physician's first report (PDF 200kb/2 pages) R12/08
11AN Naturopathic physician's invoice (PDF 122kb/1 page) R04/10
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 134kb/1 page) R04/10
83D16 Invoice for orthotic services (PDF 131kb/1 page) R04/10
83D19 Request for authorization for prosthetic services (PDF 118kb/2 pages) R01/10
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)
R10/08
8/11 Addendum Practitioner's report / Additional information (PDF 93kb/2 pages) R12/08
11A Physician's invoice (PDF 167kb/1 page)
Physician's invoice (WORD 167kb/1 page)		 R05/11
68D82 Surgical centre and diagnostic centre fax cover sheet (PDF 55kb/1 page)
Surgical centre and diagnostic centre fax cover sheet (WORD 114kb/1 page)		 R10/09
83D5 Surgical facility or medical imaging facility invoice (PDF 187kb/1 page)
Surgical facility or medical imaging facility invoice (MS Word 162kb/1 page)		 R05/10
83D6 Authorization request for expedited surgery (PDF 87kb/1 page) R10/08
83D8 Summary invoice for expedited surgery (PDF 130kb/1 page)
Summary invoice for expedited surgery (MS Word 104kb/1 page)		 R12/09
83D9 Summary Invoice for Extensive Spine Surgical Assist (PDF 114kb/1 page)
Summary Invoice for Extensive Spine Surgical Assist (MS Word 97kb/1 page)		 R05/11
83D10 Summary invoice for anesthesia (PDF 144kb/1 page)
Summary invoice for anesthesia (MS Word 166kb/1 page)		 R12/09
83D53 Surgical facility pre-authorized expense confirmation (PDF 47kb/1 page)
Surgical facility pre-authorized expense confirmation (MS Word 125kb/1 page)		 R03/09
83D56 Requisition for medical imaging (PDF 197kb/2 pages)
Requisition for medical imaging (MS Word 143kb/2 pages)		 R02/12
83D58 Requisition for expedited diagnostic and therapeutic injections (PDF 231kb/2 pages)
Requisition for expedited diagnostic and therapeutic injections (MS Word 139kb/2 pages)		 12/09
83D63 Requisition for Electrodiagnostic Studies (PDF 165kb/1 page)
Requisition for Electrodiagnostic Studies (MS Word 139kb/1 page)		 R04/12
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)		 R09/09
268 Physiotherapy report (PDF 157kb/3 pages)
Physiotherapy report (MS Word 180 kb/2 pages)		 R02/12
Form# Registered Massage Therapists Updated
83D48 Massage Therapy Report (MS Word 110kb/1 page) 02/12
267 Invoice for treatment services (PDF 77kb/1 page)
Invoice for treatment services(MS Word 117kb/1 page)		 R09/09
Form# Residential Care Services Updated
83D34 Residential Care Services monthly update (PDF 233kb/3 pages)
Residential Care Services monthly update (MS Word 232kb/3 pages)		 R06/09
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 149kb/1 page)
Residential Care Services invoice (MS Word 158kb/1 page)		 R04/10
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 monthly report (MS Word 190kb/3 pages) R02/12
83W134 Self-managed care invoice (PDF 172kb/1 page)
Self-managed care invoice (MS Word 156kb/1 page)		 R04/12
Form# Social Work Services Updated
83D64 Special Care Services Social Worker Assessment Report (PDF 203kb/6 pages)
Special Care Services Social Worker Assessment Report (MS Word 162kb/3 pages)		 01/12
83D65 Social Worker Services Invoice (PDF 155kb/3 page)
Social Worker Services Invoice (MS Word 262kb/3 page)		 R01/12
Form# General Updated
19D1 Request for Direct Deposit in Canada - Provider (PDF 131kb/1 page)
Request for Direct Deposit in Canada - Provider (MS Word 114kb/1 page)		 R03/11
25M95 Personal Care Allowance Assessment (MS Word 307kb/7 pages) R03/08
51M14 Order form for hearing loss prevention materials (PDF 81kb/1 page) R06/10
83D35 Supplier/Vendor Quote (PDF 245kb/2 pages)
Supplier/Vendor Quote (MS Word 188kb/2 pages)		 R01/11
83D38 Complex medication consultation fax cover sheet (PDF 58kb/1 page) R10/08
83D51 Generic Report - Medical and Health Care (PDF 46kb/1 page)
Generic Report - Medical and Health Care (MS Word 110kb/1 page)		 R08/09
83D59 Provider credit memo (MS Word 96kb/1 page) R05/10
83D66 Supplier/Vendor Invoice (PDF 230kb/2 pages)
Supplier/Vendor Invoice (MS Word 196kb/2 pages)		 R07/11
83D128 Generic Invoice - Medical and Health Care (PDF 151kb/1 page)
Generic Invoice - Medical and Health Care (MS Word 176kb/1 page)		 R03/11
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 170kb/2 pages) R12/11
65D28 Vocational Rehabilitation Servics vocational interest and aptitude testing final report (Word 144kb/3 pages) R12/09
65D29 Vocational Rehabilitation Services supported job placement follow-up report (Word 157kb/3 pages) R12/09
65D30 Vocational Rehabilitation Services supported job placement monthly report (Word 123kb/2 pages) R12/09
65D31 Vocational Rehabilitation Services supported job placement report (Word 146kb/3 pages) R12/09
65D32 Vocational Rehabilitation Services supported job placement intake report: Action plan (Word 146kb/3 pages) R12/09
65D33 Vocational Rehabilitation Services job-finding club intake report (Word 117kb/2 pages) R12/09
65D34 Vocational Rehabilitation Services job-finding club final report (Word 165kb/4 pages) R12/09
65D35 Vocational Rehabilitation Services individualized job placement report (Word 145kb/2 pages) R12/09
65D36 Vocational Rehabilitation Services individualized job placement intake report: Action plan (Word 146kb/3 pages) R12/09
65D37 Vocational Rehabilitation Services individualized job placement monthly report (Word 133kb/2 pages) R12/09
65D38 Vocational Rehabilitation Services individualized job placement follow-up report (Word 158kb/3 pages) R12/09
65D39 Vocational Rehabilitation Services job-search skills final report (Word 136kb/2 pages) R12/09
65D40 Vocational Rehabilitation Services psycho-vocational testing/assessment final report (Word 145kb/3 pages) R12/09
65D41 Vocational Rehabilitation Services resume and cover letter preparation final report (Word 124kb/2 pages) R12/09
65D5 Vocational Rehabilitation Services external provider invoice - generic (PDF 167kb/1 page) R04/10
65D52 Vocational Rehabilitation Services business start-up/enhancement service invoice (PDF 141kb/2 pages) R04/10
65D53 Vocational Rehabilitation Services third party agreement invoice (PDF 143kb/2 pages) R04/10
65D55 Vocational Rehabilitation Services third party agreement report cover sheet (Word 119kb/1 page) R12/09
65D56 Vocational Rehabilitation Services business start-up/enhancement report cover sheet (Word 118kb/1 page) R12/09
65D99 Vocational Reahbilitaiton Services Out-of-Province Provider Report Cover Sheet (PDF 133kb/1 page)
Vocational Reahbilitaiton Services Out-of-Province Provider Report Cover Sheet (Word 130kb/1 page)		 09/11
66D32 Vocational Rehabilitation Services sensitive claims report cover sheet (Word 120kb/1 page) R12/09
19D1 Request for Direct Deposit in Canada - Provider (PDF 131kb/1 page)
Request for Direct Deposit in Canada - Provider (Word 114kb/1 page)		 R03/11