British Columbia uses this three-section booklet to decide whether an adult qualifies for the Persons with Disabilities designation, which a person needs to receive provincial disability assistance. The applicant brings it to a physician or nurse practitioner for the Medical Report (Section 2) and to a prescribed professional for the Assessor Report (Section 3). The Ministry of Social Development and Poverty Reduction then reviews both reports against the criteria in the Employment and Assistance for Persons with Disabilities Act.
The applicant completes Section 1 and signs the declaration, and a physician or nurse practitioner registered in BC completes Section 2, the Medical Report. Section 3, the Assessor Report, can be done by that same practitioner or by another prescribed professional such as a registered nurse or psychiatric nurse, occupational therapist, physical therapist, psychologist, chiropractor or social worker.
Confirm the applicant's name, date of birth and Personal Health Number, then list each diagnosis related to the impairment using the ministry's diagnostic codes printed in the booklet, for example 5.3 for mood disorders or 13.6 for degenerative disc disease. Add the specific diagnosis, such as the type of heart or respiratory condition or the location of paralysis, and the month and year of onset if known. The form defines impairment as a loss or abnormality of psychological, anatomical or physiological structure or function that restricts the ability to function independently, effectively, appropriately or for a reasonable duration.
Describe how severe each relevant condition is and how it impairs this person; test results and other reports or findings can be used here. Record height and weight only if relevant to the impairment. Then say whether prescribed medications or treatments interfere with daily living activities and how long they are expected to continue, and whether the person needs prostheses or aids. The form's stated emphasis is on how the medical conditions and impairment affect daily living activities, not on employability.
Answer whether the impairment is likely to continue for two years or more from today, then explain the estimated duration and whether any remedial treatment could resolve or minimize it. This is the duration test in the Act: a medical practitioner or nurse practitioner must be of the opinion that the impairment is likely to continue for at least two years. Explain the reasoning behind your answer.
Check one answer each for how far the person can walk unaided on a flat surface (4+ blocks down to not at all), how many stairs they can climb unaided, lifting limits and how long they can remain seated. For walking and stairs, unaided means without another person, an assistive device or an assistance animal. Then note any communication difficulty other than English fluency and its cause, and any significant deficits in cognitive and emotional function, ticking areas such as executive function, memory, emotional disturbance or attention. Use the comments box to explain your answers.
Say whether the impairment directly restricts daily living activities, then mark each one (personal self care, meal preparation, medications, basic housework, daily shopping, mobility inside and outside the home, transportation, finances) as restricted or not, and the restriction as continuous or periodic. Continuous means needing significant help most or all of the time; periodic means needing it some of the time because the impairment is episodic. Social functioning applies only to an identified mental impairment or brain injury. Describe the specific help needed from people, equipment or assistance animals. Skip this part if you are also completing Section 3.
Add anything else that explains the significance of the conditions and their impact on daily functioning, such as hospitalizations. Record how long the applicant has been your patient and how often you saw them in the past 12 months. In the certification, physicians tick general practitioner or specialist and give their Medical Practitioner Number, while nurse practitioners give their BC College of Nurses and Midwives registration number. Sign and date to confirm the report contains your findings and considered opinion at this time.
The Assessor Report starts with where the applicant lives (alone, with family, friends or caregiver, or in a care facility) and a brief summary of the impairments that affect daily living activities. Rate speaking, reading, writing and hearing from good to unable. For walking indoors and outdoors, climbing stairs, standing, lifting, and carrying and holding, check independent, periodic or continuous assistance, assistive device, or takes significantly longer than typical, and say how much longer. Complete the cognitive and emotional functioning grid, from no impact to major impact, only for an identified mental impairment or brain injury.
For each task under personal care, basic housekeeping, shopping, meals, paying rent and bills, medications and transportation, mark independent, periodic or continuous assistance, assistive device, or takes significantly longer, and describe the type and amount of help required. Note safety issues in the comment boxes. The social functioning grid and the questions on immediate and extended social networks apply only to a mental impairment or brain injury. This is where the Act's second test is assessed: a direct and significant restriction, continuous or periodic for extended periods, that means the person requires help.
Identify who provides help (family, friends, health authority professionals, volunteers, community service agencies) and, if help is needed but none is available, what assistance would be necessary. Tick the devices routinely used, from canes and walkers to commodes, ostomy appliances or specially designed adaptive housing, and describe equipment that is needed but not yet used. Record whether the applicant has an assistance animal and what it does. Under the Act, needing help means needing an assistive device, significant help or supervision from another person, or an assistance animal.
Add anything else relevant to the impairment and its effect on daily living. Tick the approaches and sources you used, such as an office interview, home assessment, file or chart information, or input from family, caregivers or other professionals. State whether this is your first contact, how long you have known the applicant, how often you saw them in the past 12 months and what services you provide. Certify your discipline, regulatory body, registration number and employer, then sign and date.
Download the current version from the source each time; forms change without notice.
Persons with Disabilities Designation Application
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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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Section 2 must be completed by a physician licensed to practise in BC or a nurse practitioner registered in BC. Section 3 can be completed by a medical practitioner, nurse practitioner, registered nurse or psychiatric nurse, occupational therapist, physical therapist, psychologist, school psychologist, chiropractor or social worker, ideally one with a history of contact and recent experience with the applicant.
Yes. The form allows the physician or nurse practitioner who completes the Medical Report to also complete the Assessor Report. In that case, skip Part F (Daily Living Activities) of the Medical Report, as the form instructs. Physicians bill fee code 96501 for Section 2 and 96502 for Section 3; nurse practitioners can tick both sections on one invoice.
Nurse practitioners whose service contract permits billing third parties outside their 1680 deliverable hours invoice the ministry directly using the tear-off invoice at the back of the booklet. Other prescribed professionals use the same invoice for Section 3. Fill in every field, since incomplete invoices delay payment, and keep a copy of your section until you are paid.
Yes. The ministry publishes an electronic package at gov.bc.ca/PWDApp containing HR2883 and the HR4019 addendum, so applicants and health professionals can complete it on screen. The applicant should already have started an income assistance application, or be receiving assistance, before the PWD booklet is completed.