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  • SUCCEED Satisfaction Survey
    Type: Workers
    Date: September 16, 2022
  • Employer Report of Injury or Illness
    Type: Employers
    Date: August 6, 2020 Last Revised: August 11, 2022
    Description:

    Complete this form if an employee experiences a work-related injury or illness. You must submit this to WorkSafeNB within three days of the: date of the accident if the injury or illness may entitle the worker and/or their dependent(s) to wage  replacement or medical treatment under New Brunswick’s Workers’ Compensation Act; date the employee is diagnosed with an occupational disease; or date you are notified of the accident/injury or illness by the employee.

  • Application for Workers' Compensation Benefits
    Type: Workers
    Date: August 6, 2020 Last Revised: August 11, 2022
    Description:

    Submit this form when applying for WorkSafeNB benefits, such as lost wages and/or medical treatment (physiotherapy, medication, etc.), due to a workplace injury or illness. You must complete this form and send it to WorkSafeNB within one year from the date of the accident/injury or illness.

  • Report contractors and subcontractors Form
    Type: Employers
    Date: June 16, 2022
    Description:

    Form to report contractors and subcontractors must be completed and returned no later than February 28, 2021.

  • SUCCEED Mental Health Questionnaire
    Type: Health Care
    Date: May 30, 2022
    Description:

    Administer this form to workers participating in the SUCCEED program within one week of starting treatment. Re-administer at the end of treatment. 

  • SUCCEED Discharge Report
    Type: Health Care
    Date: May 25, 2022
    Description:

    Complete and submit this form within one week of treatment end date.

  • Decision Review Form
    Type: Workers
    Date: June 10, 2019 Last Revised: April 27, 2022
    Description:

    The Decision Review Office is here to review WorkSafeNB decisions if you disagree with the original decision.  Injured workers, employers or their representatives can request a review. You can request a review by completing the Decision Review form and forwarding it to the Decision Review Office

     

  • Caregiver Receipt
    Type: Workers
    Date: January 10, 2022
    Description:

    Use this receipt template for recording informal home care services performed for a worker (the client) receiving WorkSafeNB benefits.

  • Caregiver Disclosure Statement
    Type: Workers
    Date: January 10, 2022
    Description:

    Complete this disclosure statement if you plan to perform informal home care services for a worker (the client) receiving WorkSafeNB benefits.

  • Notice of Appeal (order, advice or administrative penalty)
    Type: Workers
    Date: October 28, 2021
    Description:

    Use this form to appeal an order, advice or administrative penalty (AP) issued under New Brunswick’s Occupational Health and Safety Act or its regulations. The notice of appeal must be filed within 14 calendar days of receiving the order, advice or administrative penalty.

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