This is the first medical certificate in a CNESST work-injury file. The first health professional who takes charge of the worker completes it at the first visit after a work accident, a suspected occupational disease, or a recurrence, relapse or aggravation, recording the precise diagnosis, injury sites, expected consolidation (14 days or less, or more than 14 days) and care given. The worker passes the employer's copy to the employer.
The first health professional who takes charge of the worker completes the whole form; CNESST's guide defines the treating professional as the physician, IPS, dentist, pharmacist or optometrist the worker chooses. The worker files a Réclamation du travailleur and the employer sends CNESST its Avis de l'employeur et demande de remboursement.
For a Québec beneficiary, copy the details from the health insurance card: N° d'assurance maladie, Prénom et nom à la naissance, date of birth, sex and card expiry date. For any other beneficiary, enter the worker's name, first name, date of birth and sex, and add the employer's name and address in the diagnosis box. Then enter your own name, licence number (N° de permis) and group number (N° de groupe).
Enter the date of the work accident as the original event date. For an occupational disease, the event date is the date of the medical consultation at which the disease was diagnosed. Fill in the recurrence, relapse or aggravation date only when one applies, using the date it appeared, and enter the date you examined the worker as the visit date. Dates go in year, month, day order (AAAA MM JJ).
Describe the nature of the injury or disease as precisely as possible. If the diagnosis is uncertain, you must say so; the guide's example is a probable supraspinatus tendinitis of the left shoulder. Always add the treatments prescribed or administered (nature et durée des soins ou des traitements) and their expected duration. Harassment is not a diagnosis: record the physical or psychological diagnosis that results from the workplace event.
Tick every injured site: Visage, Yeux, Dents, Oreille gauche or droite, Crâne, the Cervical, Dorsal, Lombaire or Sacré regions, Thorax, Bassin, Abdomen, or Autres (précisez) with a written description. Upper-limb (Membre supérieur) segments run from Épaule to Doigts and lower-limb (Membre inférieur) segments from Hanche to Orteils, each with a Gauche and a Droite box. CNESST asks for the side whenever a limb is injured.
The period runs from the date the worker became unable to do their job. If you expect consolidation in 14 days or less, tick “14 jours ou moins” and enter the expected consolidation date. If you expect more than 14 days, tick “plus de 14 jours” and enter the expected duration in weeks (Nombre de semaines) counted from this visit. Consolidation means healing or stabilization with no further improvement foreseeable.
Tick Oui or Non and, if you will see the worker again, enter the planned date (Si oui, date prévue). If you see the worker again during a consolidation period of 14 days or less, CNESST's guide says you may complete a new Attestation médicale at that visit. When consolidation is expected beyond 14 days, later reports go on the Rapport médical (1937).
Enter the name of the clinic or health establishment where you examined the worker, with its address, telephone and fax numbers. Sign and date the form. Tick “Cochez si professionnel de la santé non participant à la RAMQ” only if you do not participate in RAMQ. The back of the form asks you to read CNESST's Guide d'utilisation des formulaires médicaux before completing it.
Download the current version from the source each time; forms change without notice.
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Sources for this guide
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The first health professional who takes charge of the injured worker, at the first visit. CNESST's guide defines the treating professional as the physician, IPS, dentist, pharmacist or optometrist chosen by the worker. If the worker could not choose that first professional, the professional they later choose must provide the attestation when the worker asks for it.
Count from the date the worker became unable to do their job. If you expect consolidation within 14 days, tick “14 jours ou moins” and enter the expected consolidation date. If you expect longer, tick “plus de 14 jours” and enter the expected duration in weeks from your visit; a Rapport médical sommaire de prise en charge must then follow within 6 days.
Yes, when consolidation is expected within 14 days: CNESST's guide says that if you see the worker again during a consolidation period of 14 days or less, you may complete a new attestation. When consolidation is expected beyond 14 days, follow-up is reported on the Rapport médical (1937), and the Rapport final (1938) records consolidation.
No. CNESST publishes this form in French only. It exists as a fillable PDF, as paper sets ordered from CNESST, and inside CNESST-certified EMRs (DME). CNESST's guide notes that the EMR version fills in the patient's identification automatically, sends the data to CNESST in real time and produces the official copies to give the patient.