WoRK BC Initial Worker Interview
Mental Health Adjudication

Worker's last name First name Middle initial WorkSafeBC claim number

HOLAND MARK 42647461

e Overactive stress response

When did symptoms start? Elaborate as needed.
January 30, 2026 (all broke down)

Do you have any other life events or activities in your life that are affecting your mental health (either in a
negative or positive way)?

None

Have you had recent thoughts of ending your life? (yes/no)
No

Tell me about your support network

Wife, daughter, family

Date of psychological change

January 30, 2026

Return to work/Duty to cooperate/Duty to maintain employment
Only ask return-to-work questions if appropriate for worker’s situation/mental health

Our goal is to support you to get back to health and work. Early and safe RTW can help you recover from
your injury. If you think of a typical day at work and the job duties you complete:

Advised to maintain contact with AE.

Additional Comments

Ear Conditions
e Do you have any previous ear infections or conditions?
e No previous ear infections
e Do you have any known allergies?
e Lactose
e Has there been any change to your hearing or balance?

e Slight hearing change in left ear (comparing hearing test between September 2025 and most
recent test)

e Any recent travel? Where to?
e Not since October

e Any recent changes in altitude? (Flights, scuba diving, skydiving, etc.)
e None

e Any recent exposure to loud noise, water or chemicals? (e.g. a concert)
e None

Migraines

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