The treating professional sends this report once the work injury is consolidated, meaning healed or stabilized with no further improvement foreseeable. It gives the final diagnosis and consolidation date, answers whether the injury leaves a permanent impairment to physical or psychological integrity or functional limitations, and states whether you will produce the Rapport d'évaluation médicale (2064) or have referred the worker to a professional who will.
The health professional who has charge of the worker, usually the physician or IPS, completes the whole form and, by signing, attests having informed the worker of its content without delay. The worker and employer complete nothing on it.
For a Québec beneficiary, copy the health insurance card details; for any other beneficiary, enter name, first name, date of birth and sex. Add your name and licence number. The original event date is the accident date or, for an occupational disease, the date of the consultation where it was diagnosed. Add a recurrence, relapse or aggravation date only when one applies, and the date of this examination.
Enter the final diagnosis or diagnoses of the work injury, using the diagnoses CNESST accepted, as the guide instructs. The answers on consolidation, permanent impairment and functional limitations that follow all relate to this accepted injury. If a Rapport d'évaluation médicale follows, its point 1 also calls for the diagnosis accepted by CNESST.
Question 1 asks whether the injury causes a permanent impairment to physical or psychological integrity. Question 2 asks whether it causes functional limitations and, if so, whether they aggravated limitations that existed before. Tick Oui or Non for each. If you answer Non to both, no Rapport d'évaluation médicale is needed; a Oui to either means the REM must reach CNESST without delay.
If you answered Oui and will produce the REM (Code RAMQ 09944) under the Règlement sur le barème des dommages corporels, but not at this visit, enter the planned evaluation date. If you will not produce it at all, tick the box saying so, then answer whether you referred the worker to another health professional and, if Oui, give that professional's name.
Entering the consolidation date is mandatory. Consolidation is the healing or stabilization of the injury after which no improvement in the worker's health is foreseeable. Use the space below the date for comments or additional information. The date has consequences beyond the form: the worker must tell the employer without delay, and the employer must inform CNESST when it reinstates the worker.
Enter the clinic or establishment name, address, telephone and fax numbers. By signing and dating under “J'atteste avoir informé sans délai le travailleur du contenu de ce rapport”, you attest that you told the worker what the report says without delay, as the law requires. Tick the box only if you are a non-participating RAMQ professional, and give the worker two copies.
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.
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.
Sources for this guide
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At consolidation, whenever more than 14 days have passed since the worker became unable to work because of the injury, or when 14 days or less have passed but permanent sequelae or functional limitations persist. The treating professional produces a single Rapport final at the end of the consolidation period and sends it as soon as the injury is consolidated.
The treating professional is expected to do it first. If you will not, tick the box saying you are not producing it and state whether you referred the worker, with their agreement, to another health professional, giving that person's name. Without a referral, the worker chooses the evaluator and notifies CNESST, which sends that professional the file.
No. The note on the back of the form says submitting a Rapport final does not close the worker's file permanently. The file can be reopened for a recurrence, relapse or aggravation, and the reporting process set out in LATMP sections 199 to 203 (attestation, medical reports, final report) must then be repeated in full.
Enter the planned evaluation date under question 3. CNESST's guide says that a Oui to permanent impairment or to functional limitations means a Rapport d'évaluation médicale must reach CNESST without delay, and that if you cannot produce it at this visit you must give the date you plan to do the evaluation.