Filling out a WCB Incident Report

CLB Level: 4/5
Essential Skills Focus:
Document Use (Enter information on forms), Writing (scan/gather information to fill out form)
Task: Read the scenario and fill out the first 30 items
Purpose: Students will
·  Access and locate information
·  Fill out a form
·  Follow 5 step written instructions
Materials: Scenario, whiteboard, WCB worker incident report (to download a form/incident report go to http://www.wcb.mb.ca/
workers/forms.html)
Learning Style: Visual
Time: 25 to 30 minutes / Method:
1.  On the board, as a review, brainstorm the correct way to fill out forms or introduce the information if not before covered.
2.  Hand out the form and explain that this form must be completed if a worker has an accident at work.
3.  Go over the form, up to the end of “Name and Address of Doctor(s) and/or Hospital(s) that Provided Treatment”, to be sure students understand vocabulary such as “PHIN”.
4.  Explain that students are required to fill out only that part of the form on this occasion.
5.  Hand out the scenario and go over the written instructions to be sure they are clear to the students.
6.  Have the students turn over the form and read the scenario for understanding.
7.  When they have read the scenarios completely, have them fill out the form by scanning for the information.
Follow Up:
Go over the rest of the form with the students to be
sure they understand the information required.
Similar scenarios can be created to complete other
parts of the form. Also, a wide variety of other forms
will be filled out in future classes.
Debrief/Transfer:
What did we do?
Why did we do this?
How can we apply this to our lives?

Filling out forms: Reporting a Claim to the Workers Compensation Board

Please turn your application form face down. First read the following story. Then, scan for the information to fill out the first part of the application form for Walter. Please remember: When you complete the section describing the incident in detail, use “I”, not “he” because Walter is telling you what to say. You are only his secretary because his hand is too sore to write.

Your co-worker, Walter Sushky, was injured on Friday, October 24 at your place of employment – Kitchen Craft, located at 1180 Springfield Road. The postal code is R2C 2Z2 and the phone number is 224 – 3211. You are helping Walter report his claim to the Workers Compensation Board because Walter is left-handed and he cut his left thumb deeply at work while using a table saw. His thumb required 4 stitches. He had just started his shift. Walter is a cabinetmaker. He was cutting a large sheet of plywood into smaller pieces that would be used to make cabinet doors. The piece of plywood jammed in the saw. When he was trying to get the sheet of plywood out of the saw, his thumb slipped and the saw cut right through his left thumbnail and up to the first joint of his thumb. The accident was not his fault. The blade of the saw was loose, but the person using the saw during the previous shift never reported the damage to the supervisor. It was that person’s responsibility. Two of Walter’s co-workers, Don Smith and John Brownly saw the accident happen.

Walter knew that it was his responsibility to report the accident to his supervisor, Frank Johnson, immediately. Frank wrapped Walter’s hand in a clean towel and had one of Walter’s co-workers, Sam Simpson, drive Walter to the Concordia Hospital at 1095 Concordia Avenue. They went to the Emergency Department and the nurse on duty asked for Walter’s Personal Health Identification Number which was on the back of his Manitoba Health Card. It was 105 827 844. He almost gave the nurse his Social Insurance Number, 675 123 456, by accident. Walter got 4 stitches. The doctor then bandaged his thumb and gave him some painkillers to take in case the pain was too strong later. On October 28, Walter had his thumb checked by his family doctor, Dr, Ray Singer, at 1001 Corydon Avenue. His finger was starting to heal nicely, with no signs of infection.

After the hospital visit on October 24, Sam Simpson drove Walter home, but before he left the hospital, he decided to call his wife at home. He was so confused that he had trouble remembering his own phone number as he dialed 338 – 2414. Walter lives at 607 Leila Avenue. His postal code is R2V 3R7. Walter is a young employee because he was born on April 23, 1985.

Winnipeg School Division Adult EAL Program Essential Skill Focus: Document Use / Writing

Author: Mary Ward CLB level: 4/5