Application for Compensation and

Report of Injury or Occupational Disease

If you have any questions, please call our Contact Centre at 604.231.8888 or toll-free at 1.888.967.5377.

Worker first name: Worker last name: PHN: SIN: Claim number:
MARK HOLAND 9128-549-738 730-742-368 42647461

Third party involvement

Third party involved? Type:
No

Third party's (other individual or driver) name, phone number, and/or other details:

Injury information

Injury description:

Pain in the left ear and migraine symptoms, worker feels it is related to noise coming from servers in their
training class.

Prior injuries?
Yes

Prior injuries explanation:
Prior and ongoing migraines.

First aid treatment information

Received first aid? Date:
No

Treatment:

Hospital treatment information

Hospital visit? Date: Hospital:

Yes January 25, Royal Columbian Hospital
2026

Treatment:

Medication: Tylenol.

Imaging: No.

Healthcare treatments: No.
Specialist Referral: No.
Time-off: As needed.
Follow-up: TBD

Worker followed up with Royal Columbian Hospital on Jan 30th, the worker was having stress and anxiety
symptoms. The worker was provided with prednisone for the ear pain.

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