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Western Survey


QUESTIONS
1. Employer / Placement Site Organization Name:
2. Employer / Placement Site Contact Name:
3. Contact Email Address:
4. Contact Telephone Number:
5. Contact Address:
6. Please indicate whether your organization has WSIB coverage under the Workplace Safety and Insurance Act:

Section 1


7. Please select YES if you have read the following:

Process for Workplace Safety and Insurance Board coverage: 

The Ministry of Training, Colleges and Universities (MTCU) has implemented a new streamlined process for students enrolled in an approved Ontario university program that requires them to complete placements in the workplaces as part of their program of study.

The Workplace Educational Placement Agreement (WEPA) Form has been replaced by the Postsecondary Student Unpaid Work Placement Workplace Insurance Claim Form. Placement Employers and Training Agencies (universities) are not required to complete and sign the online Postsecondary Student Unpaid Work Placement Workplace Insurance Claim Form for each placement that is part of the student’s program of study in order to be eligible for WSIB coverage. Instead, this form only needs to be completed when submitting a claim resulting from an on-the-job injury/disease. Please note that universities will be required to enter their MTCU- issued Firm Number in order to complete the online claim form.

The new form has been posted on the Ministry’s public website at:

http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?OpenForm&ACT=RDR&TAB=PROFILE&SRCH=&ENV=WWE&TIT=1352&NO=022-13-1352E (English) or

http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?OpenForm&ACT=RDR&TAB=PROFILE&SRCH=&ENV=WWF&TIT=1352F&NO=022-13-1352F  (French)

Please note that all WSIB procedures must be followed in the event of an injury/disease. Universities will keep the signed original of the placement letter on file and ensure that Placement Employers have a copy.
 

Section 2


8. Please select YES if you have read the following:

Process for ACE-INA coverage through MTCU

MTCU also covers the cost of private insurance with ACE-INA for Student Trainees enrolled in an approved program at Western and participating in unpaid work placements with employers who do not have coverage under the Workplace Safety and Insurance Act. The new Form referred to above must also be completed and submitted to the University in the event of an on-the-job injury/disease at these sites.

9. In selecting "yes" from this drop down, I, as an authorized representative, confirm our commitment to immediately report any workplace injuries or disease to the relevant Program at Western.:
10. Date of Submission:

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