C139 – Employer’s Information Questionnaire (WCB Alberta) Instructions

Enter any extra information, clarifications or remarks related to the employee’s employment history, safety precautions, hearing assessments, or other relevant details that were not captured elsewhere on the form.

Enter the Workers' Compensation claim reference number assigned to this case exactly as it appears on your correspondence or prior forms.

Enter the company's full legal or trade name as it should appear on the form.

Enter the company's primary telephone number, including area code and any extension if applicable.

Enter the full name of the company contact person, printed clearly (first and last name).

Enter the contact person's job title or position within the company.

Provide the date the worker's employment with this employer ended or leave blank if still employed.

Provide the date the worker began employment with this employer.

Enter the full legal name of the employer or company that hired the worker.

Enter the starting date of the employment period for this first row.

Enter the ending date of the employment period for this first row.

Enter the job title or occupation held during this employment period.

Enter the province or territory where the work was performed for this employment entry.

Enter the start date for this period of employment.

Enter the end date for this period of employment.

Enter the job title or occupation held during this period of employment.

Enter the province or territory where this employment took place.

Enter the employment start date for the third listed job.

Enter the employment end date for the third listed job, or leave blank if the employment is ongoing.

Enter the job title or occupation held for the third listed employment.

Enter the province (or state) where the third listed employment took place.

Check this box when audiograms were performed for the worker and you are including copies of all audiogram records with this form.

Enter the telephone number (including area code) for the person or organization listed as the source of the audiogram copies. Fill only if 'Hearing assessments have not been completed for our employees' is 'Yes'.

Enter the full name or organization name that can provide copies of the audiograms. Fill only if 'Hearing assessments have not been completed for our employees' is 'Yes'.

Check this box when audiograms were performed but copies are not attached; provide the name and telephone number where the audiogram copies can be obtained.

Check this box when no hearing assessments or audiograms have been conducted for the worker(s) at your workplace.

Check this box if hearing assessments were not completed for the employee(s) in question (i.e., no hearing assessment or audiogram exists for these employees).

Check this box when no noise level measurements were taken for the job or area being documented.

Check this box when you are providing (or will provide) a list of equipment, tools, or machinery that the worker used or that were located near the work area in lieu of noise readings.

Enter the equipment, tools, machinery, or other items the worker would have used or that would be located near the work area; list multiple items on separate lines or separated by commas. Fill only if 'Noise level readings have not been taken' is 'Yes'.

Check this box when noise level readings were performed and physical or electronic copies of those readings are attached to the form.

Check this box when noise level readings were taken and copies are available from the contact named on the lines (then provide the contact name and telephone number).

Enter the telephone number (including area code) of the contact who can provide the noise level readings. Fill only if 'Noise level readings have been taken and copies can be obtained from:' is 'Yes'.

Enter the full name of the person or organization from whom copies of the noise level readings can be obtained. Fill only if 'Noise level readings have been taken and copies can be obtained from:' is 'Yes'.

Check this box if the employer provided hearing protection to the worker.

Check this box if the employer did not provide hearing protection to the worker.

Check this box if hearing protection was provided to the worker.

Check this box if hearing protection was not provided to the worker.

Enter the date when the form was signed in the indicated year/month/day format.

Enter the full printed name of the contact person or the individual completing/signing this form.

Enter the date before which the employer has no personnel files and therefore cannot confirm the worker's employment.

Check this box if the employer has no personnel records that go back to the date requested (enter the cutoff date on the line provided).

Enter the previous company or owner name that operated the business prior to the change in ownership. Fill only if 'We have no personnel files dating back beyond this date' is 'Yes'.

Enter the new or current company name under which the business now operates after the ownership change. Fill only if 'The company has changed ownership (may contact former owner)' is 'Yes'.

Check this box if the company changed ownership on the date shown and you are directing the requester to contact the former owner (provide the ownership date and former owner's contact/name on the lines).

Provide the phone number and full address at which the company or new owner can be contacted. Fill only if 'The company has changed ownership (may contact former owner)' is 'Yes'.

Check this box if you searched company records and asked long‑time employees and still could not confirm the worker’s employment with your company.

Explain what was searched or other relevant details describing why employment cannot be confirmed (for example locations checked, dates, departments, or search steps taken). Fill only if 'Other (Please explain)' is 'Yes'.

Check this box if none of the listed reasons apply and provide an explanation in the space provided.

Enter the worker's family name or surname exactly as it appears on official records.

Enter the worker's given or first name as used on official records.

Enter the worker's initials (e.g., first and middle name initials) used to identify the worker.

Enter the worker's date of birth.

Enter the worker's job title or occupation at the time of employment or injury.

Enter the worker's Social Insurance Number (SIN) as shown on official documentation, using the full set of digits.