CNESST's medical certificates and reports for work injuries, plus IVAC's crime victim forms, with official French names, English glosses and how each reaches the agency.
CNESST handles workplace injury claims in Quebec and also administers IVAC, the crime victims compensation program. For a work injury, the first health professional consulted completes the Attestation médicale (form 1936, medical certificate). The treating professional follows with the Rapport médical (1937, medical report) and, at consolidation, the Rapport final (1938, final report). Physiotherapists, occupational therapists and psychologists have their own CNESST reports, due within 15 days of CNESST's request or of the last session.
CNESST publishes its health professional forms in French only, citing the Charter of the French language, and IVAC's forms are French only too. Medical forms go from a CNESST-certified EMR, as a PDF through Envoi de document, or on paper. Physicians bill RAMQ with the code printed on the form, and CNESST pays. For a proposed temporary assignment, you complete sections G to J of the Assignation temporaire d'un travail (2001). Vero Documents fills the PDFs from the visit note and the chart.
Medical Certificate
First medical certificate, completed at the first visit for a work accident, a suspected occupational disease, or a recurrence/relapse/aggravation. It records the precise diagnosis, the injury site(s), the expected consolidation (14 days or less, or more than 14 days) and the care given.
1937Medical Report (initial-care summary or progress report)
Report from the treating professional on an employment injury. Tick 'Sommaire de prise en charge' when consolidation is expected more than 14 days after incapacity began (one per event, sent within 6 days of the first exam). Tick 'D'évolution' at any visit where the nature or duration of care changes significantly.
1938Final Report
Report at consolidation. It gives the final diagnosis and the consolidation date, states whether there is a permanent impairment to physical or psychological integrity and/or functional limitations, and says whether the professional will produce the Rapport d'évaluation médicale or refer the worker to another professional.
Medical Evaluation Report
Post-consolidation assessment (REM) covering 12 points: diagnosis, complaints, history, treatment, physical or mental exam, tests, aggravation, bilaterality, permanent functional limitations, other systems, conclusion and sequelae. Sequelae are given as codes and percentages under the Règlement sur le barème des dommages corporels.
Temporary Work Assignment
The employer proposes one or two temporary assignments. The treating professional states the temporary functional limitations and answers the three LATMP s.179 questions: the worker can reasonably do the work, it is safe, and it favours rehabilitation.
1166Certificate for Reassignment or Preventive Withdrawal of a Pregnant or Breastfeeding Worker
Pour une maternité sans danger program (LSST s.40/46). Certifies that the worker's working conditions pose physical dangers to the unborn or breastfed child, or to the worker because of her pregnancy, and opens her right to reassignment or preventive withdrawal.
Written Supplementary Medical Information
Written request (IMCE) from a CNESST médecin-conseil asking the treating professional to clarify the file. Typical topics: causal relationship, diagnosis-treatment link, consolidation period, functional limitations, permanent impairment, or a pre-existing condition.
Supplementary Report
Lets the treating professional support their conclusions when the employer's or CNESST's designated professional disagrees on diagnosis, consolidation, care, permanent impairment or functional limitations, before the file goes to the Bureau d'évaluation médicale (BEM).
Request for Authorization to Implement a Rehabilitation Measure Before Consolidation of the Employment Injury
CNESST asks the treating professional to approve rehabilitation measures before consolidation, such as a gradual return to job tasks, functional capacity evaluation or development, psychosocial services, workstation or vehicle adaptation, or retraining.
Request for Treatment Authorization – Physiotherapy/Occupational Therapy
The clinic asks CNESST to authorize physiotherapy or OT for a worker with a recurrence, relapse or aggravation of an employment injury.
Physiotherapy Report
Physiotherapy report requested by CNESST for a worker treated on the treating professional's prescription. It covers health status during treatment, problems found and the treatment plan.
Evaluation Report – Psychosocial Intervention in Rehabilitation
Psychosocial needs assessment report for services CNESST requests under a professional-services contract. It addresses personal difficulties from the injury that hinder social or occupational rehabilitation.
Progress Report or Final Report – Psychosocial Intervention in Rehabilitation
Progress or end-of-plan report for psychosocial rehabilitation services provided at CNESST's request.
Psychological, Psychotherapeutic or Neuropsychological Evaluation Report
Initial evaluation report after assessing a worker referred by the treating professional's prescription, once CNESST's 'Demande de soins' has been received. It covers history, factors affecting function and return to work, the worker's perception, and the treatment plan.
Progress Report – Psychological, Psychotherapeutic or Neuropsychological Intervention
Progress report during psychological, psychotherapeutic or neuropsychological treatment of an injured worker.
Final Report – Psychological, Psychotherapeutic or Neuropsychological Intervention
End-of-intervention report for psychological, psychotherapeutic or neuropsychological treatment of an injured worker.
Occupational Therapy Report
Occupational therapy report requested by CNESST for a worker treated after an employment injury. It covers health status, problems found and the treatment plan, including return-to-work arrangements.
Statement of Account for Psychology or Psychotherapy Care or Services
Invoice for psychology, psychotherapy or neuropsychology care given to an injured worker. Its 'Informations communes aux rapports' page must be attached to each evaluation, progress and final report.
Statement of Account for Physiotherapy or Occupational Therapy Care and Treatment
Billing statement and attendance record for physiotherapy or OT care given to an injured worker. It is sent after the initial evaluation and at the end of treatment, with the end date entered.
Medical Certificate (IVAC)
First medical certificate for a victim of a criminal offence or a rescuer (sauveteur). It covers diagnosis, expected consolidation, whether the person could carry on usual activities, follow-up and referral.
Medical Report (IVAC)
Follow-up medical report by the physician following a crime victim or rescuer, produced whenever the nature or duration of care changes significantly.
Final Report (IVAC)
Report at consolidation of a crime victim's or rescuer's injury. It states the consolidation date and whether permanent sequelae or functional limitations exist, which then calls for a REM.
Progress Report – Psychotherapeutic or Psychosocial Rehabilitation (IVAC)
Progress report on psychotherapeutic or psychosocial rehabilitation, with recommendations on continuing treatment, which IVAC uses to justify ongoing funding.
Initial Evaluation Report – Psychotherapeutic or Psychosocial Rehabilitation (IVAC)
Initial evaluation report giving IVAC an overall picture of the victim's or rescuer's situation in relation to the recognized offence or rescue, after the first sessions.
Statement of Account for Psychotherapeutic or Psychosocial Intervention Services (IVAC)
Invoice for psychotherapeutic or psychosocial rehabilitation sessions with a crime victim or rescuer: session dates, initial evaluation, intervention and totals.
Final Report – Psychotherapeutic or Psychosocial Rehabilitation (IVAC)
End-of-follow-up report: conclusions, the person's own perception, results against objectives and reasons for ending. It can support a lump-sum claim for permanent sequelae or temporary impairment when no significant improvement remains possible.
Attestation by a Support Worker or Professional (IVAC)
Supporting document attesting that the victim disclosed the criminal offence (description, date and place). It is one of the accepted ways to provide the mandatory document that accompanies an IVAC request.
Transmittal Slip – Prophylactic Medication Costs (IVAC)
Fax cover sheet a pharmacy uses to claim reimbursement from IVAC for prophylactic medication dispensed to a crime victim.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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No. CNESST's forms and pages for health professionals are French only, under section 16 of the Charter of the French language. IVAC's forms are French only as well, and IVAC reimburses psychotherapy reports only when they are written in French on its template. The English names in this library are translations, not official titles.
The first health professional the worker consults: a physician, IPS (nurse practitioner), dentist or optometrist. Complete it at the first visit for a work accident, a suspected occupational disease, or a recurrence, relapse or aggravation. It records the diagnosis, the injury sites, the expected consolidation (14 days or less, or more) and the care given. Keep one copy, send one to CNESST, and give two to the worker, one of them for the employer.
The professional following the pregnancy or postnatal care: a physician, IPS or midwife. The Certificat visant l'affectation ou le retrait préventif de la travailleuse enceinte ou qui allaite (form 1166, certificate for reassignment or preventive withdrawal) belongs to the Pour une maternité sans danger program. CNESST requires the printed certificate it supplies, ordered in advance. Assess the dangers against the national public health director's (DNSP) protocols, and issue a new certificate for the breastfeeding period.
IVAC, the crime victims compensation program CNESST administers, has its own French-only medical forms. The physician or IPS completes the Attestation médicale (227, medical certificate), Rapport médical (228, medical report) and Rapport final (229, final report). For later stages IVAC uses CNESST's Rapport d'évaluation médicale (2064). Registered psychotherapy and psychosocial providers use IVAC's Word templates: Rapport d'évaluation initiale (257, initial evaluation), Rapport d'évolution (256, progress) and Rapport final (259, final report).