Québec's Ministère de l'Emploi et de la Solidarité sociale uses the SR-2100 report to decide whether a person has temporary, prolonged or permanent health constraints, for last-resort assistance under the Social Assistance or Social Solidarity programs. The professional records the diagnosis, severity and prognosis, codes the functional limitations and their expected duration, and says whether they prevent work or employment-preparation activities.
Physicians, specialized nurse practitioners, psychologists, social workers and couple and family therapists may complete Sections 2 to 5 and sign. The person fills in Section 1 and signs the Section 6 consents, which are printed in French and English.
Download the current version from the source each time; forms change without notice.
Rapport d'évaluation médicale ou psychosociale
Medical or Psychosocial Assessment Report
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The back of the form lists the authorized professionals: physicians, specialized nurse practitioners, psychologists, social workers, and couple and family therapists. Section 5 records the professional's licence number and profession, whether they provide the person's clinical follow-up and since when, and whether the ministry's evaluator may contact them.
The form itself is in French, with the person's consents printed in both French and English. The form notes that a courtesy English translation is available on Québec.ca, which can help when going through the form with an English-speaking patient.
Besides asking whether the limitations prevent the person from entering the labour market, Section 3 asks whether they prevent activities that prepare for work, such as literacy training, secondary or technical training, job-readiness projects of at least 20 hours a week, or employment assistance services.