Long Form template

Before you begin

This is a long form template, it can be used in multiple situations and projects, specially when you need to capture large amounts of data. This design slices the page into sections, and each section contains a form block.

Employers are only eligible for reimbursement if an employee's leave is due to a COVID-19 related circumstance and the leave was taken between May 20, 2021 and December 31, 2021. Find out more.

Worker's profile

This is a brief, optional explanation about the section below.

First name

Middle name

Last name

Birth date

Gender

Last 4 digits of SIN

Worker's occupation details

This is a brief, optional explanation about the section below.

Industry classification unit (CU)

Years in occupation

Position or job title

Occupation code

511255 Avalanche crew

Worker's reimbursements

This is a brief, optional explanation about the section below.

Employee's first name

Please provide a valid claim number

Employee's last name

Please provide a valid claim number

Social Insurance Number

Days of reimbursement

1 Day

2 Days

3 Days

Day 1 date

Gross salary for day 1

.00

Amount for reimbursement

$150.00

Day 2 date

Gross salary for day 2

.00

Amount for reimbursement

$200.00

Add employee

Total: $350.00

Worker's occupation details

This is a brief, optional explanation about the section below.

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Agree and submit

I confirm that the technician who conducted the test determined the test category and counseled the worker about the test results.

I confirm that the technician who conducted the test counseled the worker about hearing protection.

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