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Business to Business (B2B) Form 7 eService
Guidelines & Specifications
Abstract Form 7 field layout and characteristics for B2B Form 7 submitting
Date of Issue September 26, 2007
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Table of Contents 1 INTRODUCTION............................................................................................................................... 3
1.1 ABOUT THIS MANUAL................................................................................................................... 3 1.1.1 Purpose and audience............................................................................................................. 3 1.1.2 Usage...................................................................................................................................... 3 1.1.3 Attachments ............................................................................................................................ 3
1.2 OVERVIEW OF REPORTING REQUIREMENTS ................................................................................. 4 2 OVERVIEW OF B2B FORM 7 ESERVICE.................................................................................... 4
2.1 DEFINITION OF B2B FORM 7 ESERVICE........................................................................................ 4 2.2 SECURITY LAYER......................................................................................................................... 4 2.3 PROTOCOL LAYER........................................................................................................................ 4 2.4 INFORMATION LAYER .................................................................................................................. 5 2.5 EMPLOYER APPLICATION REQUIREMENTS ................................................................................... 5
3 SPECIFICATIONS............................................................................................................................. 5 3.1 CONNECTIVITY............................................................................................................................. 5 3.2 MESSAGES ................................................................................................................................... 6 3.3 XML............................................................................................................................................ 6 3.4 SECURITY SPECIFICATIONS .......................................................................................................... 6 3.5 GETTING AUTHORIZED................................................................................................................. 6 3.6 MESSAGE SPECIFICATION SUMMARY........................................................................................... 6
3.6.1 Message Specifications: Sign on............................................................................................. 7 3.6.2 Message Specifications: Submission ...................................................................................... 7 3.6.3 Message Specifications: Acknowledgement............................................................................ 7
4 OVERVIEW OF CLIENT DEVELOPMENT & IMPLEMENTATION...................................... 8 4.1 TEST SUBMISSIONS ...................................................................................................................... 9 4.2 TEST SUBMISSION SUPPORT ......................................................................................................... 9
5 USING THE B2B FORM 7 ESERVICE PRODUCTION ENVIRONMENT............................... 9 5.1 PRODUCTION SUPPORT................................................................................................................. 9
APPENDIX A - FIELD LIST.................................................................................................................... 11 APPENDIX B - SYSTEM ERROR RESPONSES................................................................................... 11 APPENDIX C - SCHEMAS....................................................................................................................... 11
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1 Introduction Welcome to the guidelines and specifications for the WSIB Business to Business (B2B) Form 7 eService. This service provides an efficient mechanism for Ontario employers to electronically submit their report of a workplace injury or illness in an expedient manner with immediate confirmation of receipt. Thus, helping to avoid late filing fees.
1.1 About this manual
1.1.1 Purpose and audience This document provides guidelines for employers intending to use the B2B Form 7 eServices as well as a technical specification for systems development to interface with the B2B Form 7 eService. It is also intended for vendors or employers who want to extend or develop their Occupational Injury/Illness/Disease Management and Reporting (OIIDMR) applications to be able to submit workplace injury or illness information to the WSIB using the B2B Form 7 eService. The intended audience includes project managers, business, system and programmer analysts, database administrators, and application developers.
1.1.2 Usage The main focus of this document is to assist vendors and employers who want to extend or develop their OIIDMR systems with the ability to submit workplace injury or illness information to the WSIB using the B2B Form 7 e Service channel. Although implementation details may vary from system to system, applications will be deemed compliant as long as the interface and data format specifications outlined in this document are met. This document only addresses interfacing and submitting a Form 7 to the WSIB using the B2B Form 7 eService. It does not cover applications used in the employer's environment to interface with this service.
1.1.3 Attachments While it can be indicated on Form 7 that attachments or additional documentation will accompany the Form 7 being submitted, the B2B Form 7 eService will not accept attachments or any additional documentation. Additional documentation should be faxed to the WSIB using the existing fax numbers - 1 888 313-7373 / 416 344-4684. NOTE: To assist in matching the faxed documentation with the B2B submitted Form 7, please include the B2B Form 7 confirmation number on each page of the documentation being faxed.
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1.2 Overview of Reporting Requirements Employers must report an incident to the WSIB within 3 days if a worker:
• Loses time from work or • Earns less than a regular day's pay or • Gets health care treatment.
Some examples of covered health care costs are doctors' visits, prescriptions, care in hospitals and other health facilities, physiotherapy, chiropractors' visits, eye glasses and prostheses.
An employer's obligation and the guidelines for reporting a workplace injury can be found on the WSIB website under the Employers section or at http://www.wsib.on.ca/wsib/wsibsite.nsf/public/EmployersInjuryandillness.
2 Overview of B2B Form 7 eService
2.1 Definition of B2B Form 7 eService The B2B Form 7 eService is a system which receives data submitted from an employer's OIIDMR application in an eXtensible Markup Language (XML) format and transfers it to the WSIB’s Claims Process. By creating a Form 7 in the form of an XML message, an employer can send accident information to the WSIB, across the Internet, and receive a positive confirmation of acceptance (or rejection) response - also in the form of an XML message. Upon receiving a Form 7 report, the B2B Form 7 system validates the data against business rules (as defined in the Form 7 Field List) and transfers the XML data to the Claims Process. Any XML submissions that do not pass the validation will be rejected, the submitted data will not be saved and an appropriate status message will be returned to the submitter so that the problem can be corrected and re-submitted.
2.2 Security Layer Employers are able to access the B2B Form 7 eService only after registering with the WSIB to use the service. Only requests carrying the credentials of registered employers will be processed. Contact information for registration will be posted on the WSIB website. Developers will require a test ID and password to submit a 'test' Form 7 in order to perform an end-to-end test. Contact information for obtaining test credentials will be posted on the WSIB website. **BETA test period** BETA testing participants will be contacted by the B2B Form 7 project team in order to receive their credentials.
2.3 Protocol Layer The B2B Form 7 eService uses HTTPS - Hyper-Text Transfer Protocol with Secure Sockets Layer) encryption - for transporting XML messages. This is the only available interface to
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the system and all communications must be encrypted. A submitting application must be able to access the Internet via HTTPS in order to communicate with the eService. Employers using proxy servers may have additional coding requirements depending on the proxy’s configuration.
2.4 Information Layer XML is a meta-language, like HyperText Markup Language (HTML), that enables cross-platform data interchange using a standard method for encoding and formatting information. Unlike HTML, XML lets you publish information about a data’s structure and its meaning or context.
2.5 Employer Application Requirements The basic employer application requirements are as follows:
• Capture all injury/illness report information as defined by the WSIB current official Form 7 Report
• Provide a mechanism for the user to send the report to the WSIB B2B Form 7 eService
o Connect to B2B Form 7 eService over the Internet via HTTPS o Send UserID & Password credentials for authentication o Send the injury/illness report information formatted in an XML message that
is compliant with the WSIB Form 7 schema specification • Adhere to the business rules for information requirements (see Form 7 Field List) • Receive, log and process status and error messages
3 Specifications This section contains detailed specifications describing all acceptable message transmissions that the WSIB can process and all responses WSIB can generate. Using this specification, an employer or a 3rd party vendor can construct a computer system capable of generating and receiving such messages. Upon successful validation of an incoming message, the submission will be fed into the claims process.
3.1 Connectivity All transmissions (outgoing and incoming) must be encrypted using the Secure Socket Layer (SSL) v3 protocol - often referred to as HTTPS. When using a test ID, the test data will be validated, but the submission is not logged, stored or forwarded on to the claims process. For real submissions, the B2B Form 7 eService URL is: https://eservices.wsib.on.ca/b2bf7/ For test submissions, the B2B Form 7 Specifications Testing Service URL is: https://eservices.wsib.on.ca/b2bf7sts/
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3.2 Messages As defined in Appendix C - Schemas, valid messages may consist of a userid and password, an XML payload, and additional fields (if required). Each submission message should only contain 1 Form 7. When a schema is revised, the new schema will be published on the WSIB website as a replacement to the existing one. To assist in the transition to the new schema, XML messages that use the existing or old schema will be allowed for a period of 6 months from the publish date for the new schema. After which time, messages using an old schema will be rejected.
3.3 XML The B2B Form 7 eService uses Extensible Markup Language (XML) version 1.1 as defined by the W3C (http://www.w3.org/2001/XMLSchema ).
3.4 Security Specifications Employers must have valid credentials (userid and password) issued by the WSIB. The credentials must be submitted in order to authorize the employer user to submit Form 7 information to the B2B Form 7 eService. Multiple Form 7's may be submitted within an authenticated session, but the session will be terminated after 2 minutes of inactivity.
3.5 Getting Authorized Contact information for obtaining test or production credentials will be posted on the WSIB website. **BETA test period** BETA testing participants will be contacted by the B2B Form 7 project team in order to obtain the proper credentials.
3.6 Message Specification Summary To facilitate the development of systems, the detailed requirements for submitting a Form 7 via the B2B Form 7 eService are captured in the field list and the schemas identified in the appendices of this document. The following messages are accepted or generated by the B2B Form 7 eService:
• B2B Form 7 Sign on Message • Form7 Message • Acknowledgement Message
Each message must be constructed as defined in the appropriate schema. The Acknowledgement messages returned to the employer for submissions that fail validation are defined in Appendix B – System Error Responses
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3.6.1 Message Specifications: Sign on Each sign-on message will only contain the WSIB provided UserID and Password credentials in the form of an HTTPS Request. The format for authentication is: Authentication?UserId=myusername&Password=mypassword The Acknowledgement Message will be returned to indicate the results of the credentials authentication.
3.6.2 Message Specifications: Submission Each message may only contain one Employer’s Report of Injury/Illness (Form 7). The message content for a submission could vary depending on the incident or injury type being reported, but a message must adhere to the business rules as defined in the Form 7 Field List document (i.e. mandatory fields). The format for submission is: SubmitForm7?authHandler=XXXXXXXXXXXXXXXXX
3.6.3 Message Specifications: Acknowledgement The message syntax for an Acknowledgement message returned to the employer may vary but will fall under one of the following categories:
• Accepted credentials • Rejected credentials • Accepted submission based on compliance with the business rules as defined in the
Form 7 Field List document • Rejected submission based on non-compliance with the business rules as defined in
the Form 7 Field List document If the credentials are valid, a session is established for the submission of the Form 7 XML data. A positive response message returned to the employer for a validated report of injury/illness will include a unique identifier for the submission - referred to as a Confirmation Number. This identifier, along with the submission date and time, ties the incident stored in the employer’s system to the submission received by WSIB’s system. When contacting the WSIB to inquire about a B2B Form 7 submission, please have ready -
• Confirmation number provided when submission was accepted • Date Form 7 was submitted • Employer telephone number • Worker's last name • Worker's date of birth • Date of accident from the submitted Form 7
- so that we can locate your submission quicker.
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Submission Error Specifications Before a message will be accepted, it must be validated against the Form 7 schema. At this point, additional business logic validation is conducted and rule violations will be returned to the employer system so that the user can correct the problem. Only after all rule violations are corrected will the document be accepted, a confirmation number returned to the client and the submission entered into the claims process. Every XML message received from a registered employer will be acknowledged with an electronic reply message. If the WSIB is unable to process the message, a deterministic error codec and message shall be attached to the reply. Submission errors fall into three basic categories:
• Server Faults • Security Faults • Schema Faults / Business Logic Faults
Server Faults Server Faults occur when there is a problem accessing the service due to connectivity problems. Security Faults The security infrastructure will protect the integrity of the service and perform credential authentication In case of a security fault, an appropriate response message will be generated and returned to the employer. For more information, see Appendix C - System Error Responses. Schema Faults/Business Logic Faults Schema Faults occur when there are schema validation errors due to incorrectly structured XML documents. In addition, a Form 7 message must adhere to the business rules as defined in the Form 7 Field List document. Business Logic Faults occur due to errors detected by schema validation as well as additional processing of business rules and logic on the injury/illness information provided. For example - a reported incident may successfully pass the schema validation, however the employee has lost time and/or earnings and all required sections of the form are not completed. This is largely a data entry error and is easily rectified. See Appendix C – System Error Responses.
4 Overview of Client Development & Implementation The steps required to develop and implement software to access the B2B Form 7 eService are as follows:
1. The interested development party (i.e. vendor/employer) reviews this Guidelines and Specifications document - contacting the WSIB, as needed.
2. The vendor/employer registers for access to the B2B Form 7 Specification Testing Service.
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3. The vendor/employer develops/customizes client application software according to these specifications.
4. Once the client application is complete, the vendor/employer conducts extensive internal testing to ensure that the system produces a well-formed and valid XML based on the Form 7 schema.
5. The vendor/employer conducts an end-to-end test using the test credentials and the B2B Form 7 Specification Testing Service URL.
6. The vendor makes developed/customized client application available to their employer customers.
7. The employer registers for production access to the B2B Form 7 eService.
4.1 Test Submissions Vendors or employer developers with a registered test ID and password must use the Specification Testing Service URL (https://eservices.wsib.on.ca/b2bf7sts/) for test submissions. Vendors and employer developers are allowed to send requests to the B2B Form 7 Specification Testing Service URL only using the test ID. These submissions will be processed by the eService, but the data will not be stored. The submitting application will receive the appropriate B2B Form 7 eService responses. NOTE: The Specification Testing Service is not intended for client application system testing. The WSIB expects vendors/employers to thoroughly test their applications’ compliance to the B2B Form 7 specifications before they perform an end-to-end test.
4.2 Test Submission Support Developer support will be provided for test submissions. The following types of feedback will be available on request: For a successful incident submission: An acknowledgement message (in the form of Acknowledgement.xsd ) similar to the message provided for real submissions will be returned for each successful transaction. For a rejected or failed submission: A log will contain a record of each failed authentication attempt. The log will also contain a record of the submitted XML document, exactly as it was transmitted to us, and a record of any schema or business rule validation encountered for each submission.
5 Using the B2B Form 7 eService Production Environment The production URL (https://eservices.wsib.on.ca/b2bf7/) will only accept submissions from registered employer production User IDs.
5.1 Production Support The WSIB eService Help Desk is equipped to support technical issues arising from errors generated by the use of eServices. The Help Desk phone number is <TBD>
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**BETA test period** An information package will be provided to BETA testing participants - including contact information during the BETA test period.
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Appendix A - Field List Form 7 is divided into eleven sections. In order to capture sufficient worker, employer, health care provider and accident/disease information, all fields are mandatory - where it is logical to do so. Please see the Form 7 Field List document for all the fields and their characteristics.
Appendix B - System Error Responses Error Code Error Message 101 Invalid user id or password 102 Authentication required 103 User id is too long (limit = 32 characters) 10X Other authentication failure 201 Invalid XML document: Empty or blank XML document 202 XML document cannot be larger than 30K 203 Invalid XML document 20X Other XML document validation error 30X System error
Appendix C - Schemas Schemas Form7.xsd Form7BasicComplexTypes.xsd Form7ComplexTypes.xsd BasicSimpleTypes.xsd BasicComplexTypes.xsd Acknowledgement.xsd
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Business to Business (B2B) Form 7 eService
Field List
Abstract Form 7 field layout and characteristics for B2B Form 7 submitting
Date of Issue September 26, 2007
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Table of Contents
1 Form 7 Layout.....................................................................................................3
2 Field Attribute Definitions .................................................................................3
3 Field Characteristics and Business Rules .......................................................4
3.1 Section A - Worker Information ...........................................................................4 3.2 Section B. Employer Information.........................................................................5 3.3 Section C. Accident/Illness Dates and Details ...................................................6 3.4 Section D. Health Care........................................................................................10 3.5 Section E. Lost Time - No Lost Time .................................................................11 3.6 Section F. Return to Work ..................................................................................12 3.7 Section G. Base Wage/Employment Information .............................................13 3.8 Section H -Additional Wage Information...........................................................14 3.9 Section I. Work Schedule ...................................................................................17 3.10 Section J. Declaration.........................................................................................19 3.11 Section K. Additional Information .....................................................................19
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1 Form 7 Layout A. Worker Information B. Employer Information C. Accident/Illness Dates and Details D. Health Care E. Lost Time – No Lost Time F. Return To Work G. Base Wage / Employment Information H. Additional Wage Information I. Work Schedule J. Declaration K. Additional Information
Each section contains a number of data fields. Each field has been analysed to determine mandatory or optional rules and as to data characteristics.
2 Field Attribute Definitions For the purposes of this document, field attributes used in the following tables are defined as follows:
Field Attribute Definition alphanumeric Field that can contain numeric, alphabetic or character such
as, but not limited to brackets, dashes, back-slashes, forward slashes, etc.
monetary Field defined as dollars and cents i.e. $4.25 is represented as 3(2)
numeric Field restricted to numeric character 0, 1, 2, 3, 4, 5, 6, 7, 8, 9 including decimal points i.e. 4.25 is represented as 3(2)
text Freeform text field i.e. similar to alphanumeric
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3 Field Characteristics and Business Rules 3.1 Section A - Worker Information
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
Claim number O 8 numeric
Job Title/Description M 40 alphanumeric Minimum input is 1 character
Length of Time in this position working for you M 12 alphanumeric Minimum input is 1 character
Social Insurance Number M 9 numeric
Please check if this worker is a: O Check boxes: Executive, elected official, owner, spouse or relative of the employer
Allow more than one box to be checked
Is worker covered by a union/collective agreement? M Check boxes: yes, no
1 alpha Either/or rule
Worker Reference Number O 15 alphanumeric Field may be blank
Worker's preferred language M Checkboxes: English, French, Other 1 alpha Either/or rule
Other O/M 20 alpha Field is mandatory if "other" box checked Minimum input is 1 characters if field is mandatory
Date of Birth - DDMMYY M 8 numeric Convert "year" field to 4 numeric - DDMMYYYY 00000000 not allowed
Telephone Number M 13 alphanumeric (NNN)NNN-NNNN
Sex M Checkboxes: M, F 1 alpha Either/or rule
Date of Hire - DDMMYY M 8 numeric Convert "year" field to 4 numeric - DDMMYYYY 00000000 not allowed
Last Name M 25 alpha Minimum input is 1 character First Name M 20 alpha Minimum input is 1 character
Address (number, street, apt., suite, unit) M 45 alphanumeric Minimum input is 1 character
City/Town M 30 alpha Minimum input is 1 character Province M 3 alpha Minimum input is 1 character
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Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
Postal Code M 10 alphanumeric 1 minimum to 10 maximum alphanumeric character required (mailing address may be out of Canada)
3.2 Section B. Employer Information
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
Trade and Legal Name (if different, provide both) M 45 alphanumeric Minimum input is 1 character
Mailing Address M 45 alphanumeric Minimum input is 1 character City/Town M 30 alpha Minimum input is 1 character Province M 3 alpha Minimum input is 1 character
Postal Code M 10 alphanumeric 1 minimum to 10 maximum alphanumeric character required (mailing address may be out of Canada)
Telephone Number M 13 alphanumeric (NNN)NNN-NNNN Fax Number O 13 alphanumeric (NNN)NNN-NNNN
Check one: M Check boxes: Firm Number or Account Number 1 alpha
Either/or rule
Provide Number M 8 alphanumeric, or 12 numeric
If firm number box checked, field is alphanumeric and a minimum input of 1 numeric character and a maximum of 6 numeric plus 2 alpha character allowed If account number checked, field is numeric and minimum input of 1 to maximum of 12 numeric characters allowed (do not display leading zeroes
Rate Group M 3 numeric NNN Classification Unit Code M 8 alphanumeric NNNN-NNN Description of business activity M 40 alphanumeric Minimum input of 1 alphanumeric character
Does your firm have 20 or more workers? M Check boxes: Yes, No
1 alpha Either/or rule
Branch Address where worker is O 98 alphanumeric
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Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
based (if different than mailing address - no abbreviations)
City/Town O 30 alpha Province O 3 alpha Postal Code O 10 alphanumeric Alternate Telephone Number O 13 alphanumeric (NNN)NNN-NNNN
3.3 Section C. Accident/Illness Dates and Details
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
1 Date and hour of accident/ awareness of illness M 8 numeric (date)
5 alphanumeric (hour) Convert "year" field to 4 numeric – DDMMYYYY Do not allow 00000000
AM PM M Check boxes for AM, PM
1 alphanumeric
NN:NN Either/or rule 01:00 to 12:59
Date and hour reported to employer M 8 numeric (date)
5 alphanumeric (hour) Convert "year" field to 4 numeric – DDMMYYYY Do not allow 00000000
AM PM M Check boxes for AM, PM
1 alpha
NN:NN Either/or rule 01:00 to 12:59
2 Who was the accident reported to? (Name and position) M Line one – 45 alphanumeric Minimum input is 1 character
O Line two – 12 alphanumeric Telephone M 13 alphanumeric (NNN)NNN-NNNN Ext. O 6 numeric
3 Was the accident/illness: M
Check boxes for: Sudden Specific Event/Occurrence, Gradually Occurring Over Time, Occupational Disease, Fatality
Either/or rule
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Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
1 alpha
4 Type of accident/illness: M
Check boxes for: Struck/caught, Overexertion, Repetition, Fire/Explosion, Fall, Harmful Substances/Environmental, Assault, Slip/Trip, Motor Vehicle Incident, Other
Allow more than one box to be checked
Other O/M 35 alphanumeric Mandatory, if Other box checked Minimum input of 1 character required if field mandatory
5 Area of injury (body part) - (Please check all that apply) M
Check boxes for: Head, Face, Eye(s), Ear(s), Teeth, Neck, Chest, Upper back, Lower back, Abdomen, Pelvis, Left shoulder, Right shoulder, Left arm, Right arm, Left elbow, Right elbow, Left forearm, Right forearm, Left wrist, Right wrist, Left hand,
Allow more than one box to be checked
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Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
Right hand, Left finger(s), Right finger(s), Left hip, Right hip, Left thigh, Right thigh, Left knee, Right knee, Left lower leg, Right lower leg, Left ankle, Right ankle, Left foot, Right foot, Left toe(s), Right toe(s) Other 1 alpha
Other O/M 25 alphanumeric Mandatory if "other" box checked Minimum of 1 character required if field is mandatory
6 Describe what happened to cause the accident/illness and what the worker was doing at the time……
M 600 alphanumeric Minimum of 1 character required
7 Did the accident/illness happen on the employer's premises (owned, leased or maintained)?
M Check boxes: Yes, No Either/or rule
Specify where (shop floor, warehouse, client/ customer site, parking lot, etc.
M 55 alphanumeric Minimum of 1 character required
8 Did the accident/illness happen outside the province of Ontario? M Check boxes: Yes, No Either/or rule
If yes, where (city, province/state, country) O/M 50 alphanumeric Mandatory, if "Yes" box checked
Minimum of 1 character required if field mandatory
9 Are you aware of any witnesses or other employees involved in M Check boxes: Yes, No Either/or rule
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Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
this accident/illness?
If yes, provide name(s), position(s), and work phone numbers.
O/M 200 alphanumeric
(Two fields of 100 alphanumeric characters per field) 1st line mandatory if "Yes" box checked Minimum of 1 character required in 1st field Allow 2nd field to be optional and blank
10
Was any individual, who does not work for your firm, partially or totally responsible for this accident/illness?
M Check boxes: Yes, No Either/or rule
If yes, please provide name and work number O/M 100 alphanumeric Mandatory, if "Yes" box checked
Minimum input of 1 character required if field mandatory
11 Are you aware of any prior similar or related problem, injury or condition?
M Check boxes: Yes, No Either/or rule
If yes, please explain M 50 alphanumeric Mandatory, if "Yes" box checked Minimum input of 1 character required if field mandatory
12 If you have concerns about this claim, attach a written submission to this form
O Checkbox for: submission attached 1 alphanumeric Note: Attachments are not within in the scope of the B2B F7 project
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3.4 Section D. Health Care
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
1 Did the worker receive health care for this injury? M Check boxes: Yes, No Either/or rule
If yes, when: O/M 8 numeric Mandatory if yes box checked Convert "Year" field to 4 numeric - DDMMYYYY Do not allow 00000000
2 When did the employer learn that the worker received health care? O/M 8 numeric
Mandatory if "yes" box checked for Section D, question number 1 Convert "Year" field to 4 numeric - DDMMYYYY Do not allow 00000000
3 Where was the worker treated for this injury (Please check all that apply)
M
Check boxes for: Onsite health care, Ambulance, Emergency department, Admitted to hospital, Health professional office, Clinic, Other 1 alpha
Allow more than one box to be checked
Other field O/M 70 alphanumeric Mandatory if "Other" box checked Minimum input of 1 character required if field is mandatory
Name, address and phone number of health professional or facility who treated this worker (if known)
O 190 alphanumeric
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3.5 Section E. Lost Time - No Lost Time
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
1
Please choose one of the following indicators. After the day of accident/awareness of illness, this worker:
M
Check boxes for: - Returned to his/her regular and has not lost any time and/or earnings (Complete sections G and J) - Returned to modified work and has not lost any time and/or earnings (Complete sections F, G, and J) - Has lost time and/or earnings (Complete ALL remaining sections) 1 alpha
Either/or rule If Section E, 1st box checked, invoke rules for Sections G and J If Section E, 2nd box checked, invoke rules for Sections F, G and J If Section E, 3rd box checked, invoke rules for Sections F, G, H, I and J
Provide date worker first lost time O/M 8 numeric Mandatory if Section E, 3rd box checked Convert "Year" field to 4 numeric - DDMMYYYY Do not allow 00000000
Date worker returned to work (if known) O 8 numeric Convert "Year" field to 4 numeric - DDMMYYYY
Do not allow 00000000
O/M Check boxes for: Regular work, Modified work
If there is input in "Date worker returned to work" field, one checkbox must have input
2 This Lost Time-No Lost Time-Modified Worker information was confirmed by:
M Check boxes for: Myself, Other
Either/or rule
Name M 35 alphanumeric
Assumption is that "Myself" is the signatory/submitter of form 7 If "Myself" checked, "Name" field is optional If, "Other" box checked, "Name" field is mandatory Minimum input of 5 character required if field mandatory
Telephone M 13 alphanumeric (NNN)NNN-NNNN Ext. O 6 numeric
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3.6 Section F. Return to Work (Section F requires mandatory input if Section E, #1, 2nd or 3rd box checked)
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
1 Have you been provided with work limitations for this workers injury?
M Check boxes for: Yes, No 1 alpha Either/or rule
2 Has modified work been discussed with this worker? M Check boxes for: Yes, No
1 alpha Either/or rule
3 Has modified work been offered to this worker? M Check boxes for: Yes, No
1 alpha Either/or rule
If yes, was it O/M
Check boxes for: Accepted, Declined 1 alpha
Either/or rule if "Yes" box checked
If Declined please attach a copy of the written offer given to the worker
N/A N/A Attachments to the form 7 are not within the scope of this project
4 Who is responsible for arranging worker's return to work M
Check boxes for: Myself, Other 1 alpha
Either/or rule
Name O/M 45 alpha
Assumption is that "Myself" is the signatory/submitter of form 7 If "Myself" checked, "Name" field is optional If, "Other" box checked, "Name" field is mandatory Minimum input of 5 character required if field mandatory
Telephone M 11 numeric (NNN)NNN-NNNN
Ext. O 6 numeric NNNNNN Minimum of 1 character if field entered
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3.7 Section G. Base Wage/Employment Information (Section G requires mandatory input if Section E, #1, 1st, 2nd or 3rd box checked)
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
1 Is this worker (Please check all that apply) M
Check boxes for: Permanent Full Time, Permanent Part Time, Temporary Full Time, Temporary Part Time, Casual/Irregular, Seasonal, Contract, Student, Unpaid/Trainee, Registered Apprentice, Optional Insurance, Owner/Operator or (Sub) Contractor, Other
Allow more than one box to be checked
Other O/M 45 alphanumeric Mandatory if "Other" box checked Minimum input of 1 character required if field mandatory
2 Regular rate of pay $ M 7(2) monetary Greater than or equal to zero and less than or equal to 99999.99
Per M
Check boxes for: Hour, Day, Week, Other 1 alpha
Either/or rule
Other O/M 30 alphanumeric Mandatory if "Other" box checked Minimum input of 1 character required if field mandatory
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3.8 Section H -Additional Wage Information (Section H requires mandatory input if Section E, #1, 3rd box checked)
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
1 Net Claim Code or Amount: Federal
M 7(2) monetary Or 2 alphanumeric
0.00 to 99999.99 or 00 to 99 "Federal" and "Provincial" fields are both mandatory
Provincial 7(2) Or 2 alphanumeric
0.00 to 99999.99 or AN to NN
2 Vacation pay - on each cheque? M Check boxes for: Yes, No 1 alpha Either/or rule
Provide percentage % O/M 4(2) numeric Mandatory if yes box checked 01.00 to 99.99
3 Date and hour last worked M 8 numeric
Convert "year" field to 4 numeric - DDMMYYYY Do not allow 00000000
Hour M 5 alphanumeric 01:00 to 12:59
AM PM M Check boxes for: AM, PM
1 alpha
Either/or rule
4 Normal working hours on last day worked From
M 5 alphanumeric 01:00 to 12:59
AM PM M Check boxes for: AM, PM
1 alpha Either/or rule
To M 5 alphanumeric 01:00 to 12:59
5 Actual earnings for last day worked $ M 7(2) monetary 0.00 to 99999.99
6 Normal earnings for last day worked $ M 7(2) monetary 0000.00 to 99999.99
7 Advances on wages: Is the worker being paid while he/she recovers?
M Check boxes for: Yes, No 1 alpha
Either/or rule
If yes, indicate: O/M Check boxes for: Full/Regular, Other
Either/or rule if "Yes" box checked
Page 15 of 19
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
Other O/M 25 alphanumeric Mandatory if "Other" box checked Minimum of 1 character required if field mandatory
8
Other Earnings (Not Regular Wages): Provide the total of additional earnings for each week for the 4 weeks before the accident/illness. *For Rotational Shift workers - If the shift cycle exceeds 4 weeks, please attach the earnings information for the last complete shift cycle prior to the date of accident/ illness.
O
Input table for: Period - Week 1: From Date 8 numeric To Date 8 numeric Mandatory Overtime Pay $ 7(2) monetary Voluntary Overtime Pay $ 7(2) monetary Period - Week 2: From Date 8 numeric To Date 8 numeric Mandatory Overtime Pay $ 7(2) monetary Voluntary Overtime Pay $ 7(2) monetary Period - Week 3: From Date 8 numeric To Date 8 numeric Mandatory Overtime Pay $ 7(2) monetary Voluntary Overtime Pay $ 7(2) monetary Period - Week 4: From Date 8 numeric To Date 8 numeric Mandatory Overtime Pay $ 7(2) monetary
Convert "Year" field to 4 numeric - DDMMYYYY Do not allow 00000000 in date field 0.0 to 99999.99 If “From Date” has input for any period, “To Date” is mandatory Period input does not have to be sequential, allow input for any period, or combinations of periods to be selected Allow either or both “Mandatory Overtime Pay $” and “Voluntary Overtime Pay $” to be selected without selecting any Other earnings columns Allow any combination of “Mandatory Overtime Pay $, Voluntary Overtime Pay % and Other earnings columns to be selected
Page 16 of 19
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
Voluntary Overtime Pay $ 7(2) monetary
Use these spaces for any other earnings (Indicate Commission, Differentials, Premiums, Bonus, Tips, In Lieu %, etc.)
O
Period - Week 1 Commission $ 7(2) monetary Commission $ 7(2) monetary Commission $ 7(2) monetary Commission $ 7(2) monetary Period - Week 2 Commission $ 7(2) monetary Commission $ 7(2) monetary Commission $ 7(2) monetary Commission $ 7(2) monetary Period - Week 3 Commission $ 7(2) monetary Commission $ 7(2) monetary Commission $ 7(2) monetary Commission $ 7(2) monetary Period - Week 4 Commission $ 7(2) monetary Commission $ 7(2) monetary Commission $ 7(2) monetary Commission $
0.0 to 99999.99 Other earnings type may be: Bonus Commission Differentials In lieu % Other (key in) Premiums Tips Maximum 15 alphanumeric characters if “Other (key in)” selected Allow all any selection of other earnings type headers, i.e. combinations or duplications or duplications and combinations Selection of headers or input of monetary amounts is optional
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Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
7(2) monetary 3.9 Section I. Work Schedule
(Section I requires mandatory input if Section E, #1, 3rd box checked)
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
Complete either A, B or C. Do not include overtime shifts. M
Check boxes for: (A) Regular Schedule, (B) Repeating Rotational Work
Schedule (C) Varied or Irregular Work
Schedule 1 alphanumeric
Either/Or rule
(A) Regular Schedule - Indicate normal work days and hours O/M
Input boxes for: Sunday Monday Tuesday Wednesday Thursday Friday Saturday 4(2)
Mandatory if "(B)" or "(C)" not checked Input required in at least one day field Greater than 0 and less than or equal to 24 numeric character input
or, (B)
Repeating Rotation Shift Worker - Provide O/M
Input boxes for: Number of Days On 4(2) numeric Number of Days Off 3 numeric Hours Per Shift(s) 4(2) numeric Number of Weeks in Cycle
All (B) fields are mandatory if "(A)" or "(C)" not checked Input of greater than 0 and less than or equal to 99.99 days, shifts and weeks required
Page 18 of 19
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
4(2) numeric
Or, (C)
Varied or Irregular Work Schedule - Provide the total number of regular hours and shifts for each week for the 4 weeks prior to the accident/illness. (Do not include overtime hours or shifts here).
O/M
Table input fields Week 1: From/To Dates 8 numeric Total Hours Worked 5(2) numeric Total Shifts Worked 5(2) numeric Week 2: From/To Dates 8 numeric Total Hours Worked 5(2) numeric Total Shifts Worked 5(2) numeric Week 3: From/To Dates 8 numeric Total Hours Worked 5(2) numeric Total Shifts Worked 5(2) numeric Week 4: From/To Dates 8 numeric Total Hours Worked 5(2) numeric Total Shifts Worked 5(2) numeric
Mandatory if "(A)" or "(B)" not checked Convert "year" field to 4 numeric - DDMMYYYY Input required of greater than 0 and less than 999.99 or equal to hours and shifts
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3.10 Section J. Declaration (Section J requires mandatory input if Section E, #1, 2nd or 3rd box checked)
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
Name of person completing this report (please print) M 50 alpha Minimum input of 1 character required
Official Title M 50 alpha Minimum input of 1 character required Signature TBD Telephone M 13 alphanumeric (NNN)NNN-NNNN Ext O 6 numeric
Date DDMMYY M 8 numeric Convert "year" field to 4 numeric - DDMMYYYY Do not allow 00000000
3.11 Section K. Additional Information
Label Field Name
No. Input Name
Mandatory, Optional, Verified,
Selected by List
Field Characteristics Edit Rules
Additional Information O 3800 alphanumeric character Free form text field
