Rapport du professionnel de la santé (formulaire 8)
First report to the WSIB after the initial visit for a patient's work-related physical injury or illness, or when workplace factors are suspected. Page 2 goes to the employer through the patient.
- Completed by
- Physician, NP, chiropractor or physiotherapist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Détermination des capacités fonctionnelles pour la planification d'un retour au travail rapide et sécuritaire
Describes the patient's functional abilities and restrictions, without diagnosis, so the employer and worker can plan early and safe return to work. Completed only when the employer or worker requests it.
- Completed by
- Regulated health professional (physician, NP, chiropractor, physiotherapist, psychologist, etc.)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Requested by the WSIB for information on the medical indications and therapeutic benefit of a patient's opioid medication.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
Rapport du professionnel de la santé pour stress professionnel (formulaire CMS8)
First report to the WSIB for a patient's occupational (work-related) mental stress claim. Used instead of Form 8.
- Completed by
- Physician or NP only
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Physician report used for permanent disability rating when the accident happened before January 1, 1990.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
Demande de prolongation des traitements (chiropraticien)
Chiropractor's request to the WSIB to extend chiropractic treatment for a patient who is not in a program of care.
- Completed by
- Chiropractor
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Demande de prolongation des traitements de physiothérapie
Physiotherapist's request to the WSIB to extend physiotherapy for a patient who is not in a program of care.
- Completed by
- Physiotherapist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Formulaire d'évaluation dans le cadre du Programme de santé mentale communautaire
Initial mental health assessment report (diagnosis and functional impairment) for a WSIB patient referred to the Community Mental Health Program.
- Completed by
- Community Mental Health Program provider (psychologist or other regulated mental health professional)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Formulaire d'évolution dans le cadre du Programme de santé mentale communautaire
Periodic treatment progress report for a WSIB patient in the Community Mental Health Program.
- Completed by
- Community Mental Health Program provider (psychologist or other regulated mental health professional)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Recommandations concernant le retour au travail
Mental health provider's return-to-work recommendations for a WSIB patient in the Community Mental Health Program.
- Completed by
- Community Mental Health Program provider (psychologist or other regulated mental health professional)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Requested by the WSIB to assess initial coverage of medical cannabis for a work-related condition.
- Completed by
- Physician or NP
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
Requested by the WSIB to decide continued coverage of medical cannabis.
- Completed by
- Physician or NP
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
Rapport du dentiste
Dentist's report on a work-related dental injury: pre-accident history, findings, and proposed treatment and fees.
- Completed by
- Dentist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Physician's medical clearance for a patient to undergo a WSIB functional abilities evaluation.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
Sent by the WSIB to the patient's physician or NP when the patient reports an occupational illness; complete and return.
- Completed by
- Physician or NP
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
Sent by the WSIB when a patient reports a work-related skin condition; complete and return.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
Sent by the WSIB when home oxygen is prescribed for a work-related condition. Needed for initial and ongoing entitlement.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
Sent by the WSIB when a patient reports a work-related chest or respiratory illness; complete and return.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
Sent by the WSIB when a patient reports work-related vibration-induced white finger disease; complete and return.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
Rapport d'évaluation de physiothérapie
Physiotherapist's assessment report to the WSIB (patient, employer, findings and plan) for a work-related injury.
- Completed by
- Physiotherapist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Rapport d'évolution (professionnel de la santé) (formulaire 26)
Progress report on a WSIB patient's recovery and return to work. Completed when the patient brings the WSIB-issued form.
- Completed by
- Physician, NP, chiropractor, physiotherapist or RN (Extended Class)
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English and French
Rapport de consultation ORL
ENT specialist's consultation report on hearing loss, tinnitus, dizziness or balance complaints and occupational noise exposure. Typically used for noise-induced hearing loss claims.
- Completed by
- Otolaryngologist (ENT specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Rapport du professionnel de la santé (continuation d'invalidité) (formulaire REO8)
Health professional's report on a recurrence or re-injury of a previously accepted work-related condition: history, prior assessment and current status.
- Completed by
- Physician, NP, chiropractor or physiotherapist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Évaluation audiologique
Hearing assessment (audiometric results and hearing aid prescription/recommendation) for a WSIB noise-induced hearing loss claim or hearing services.
- Completed by
- Hearing health care provider (audiologist or hearing instrument specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Rapport d'évaluation initiale dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères
Initial assessment report when a patient with a work-related concussion/mTBI starts the WSIB mTBI program of care.
- Completed by
- Regulated health professional delivering the WSIB mTBI program of care
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Rapport de mi-parcours dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères
Mid-point report completed at the end of block 1 of the mTBI program of care.
- Completed by
- Regulated health professional delivering the WSIB mTBI program of care
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Sommaire des soins et des résultats dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères
Discharge care and outcomes summary for the mTBI program of care, including employment status at discharge.
- Completed by
- Regulated health professional delivering the WSIB mTBI program of care
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Report after WSIB-approved additional mTBI treatment (supplementary block).
- Completed by
- Regulated health professional delivering the WSIB mTBI program of care
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English
Formulaire de demande de technologies d'aide auditive
Request WSIB pre-approval for the initial purchase of hearing assistive technology items.
- Completed by
- Audiologist or hearing instrument specialist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Formulaire de demande de remplacement de prothèse auditive et(ou) d'exception clinique
Request approval for replacement hearing aids and/or clinical-exception-level hearing aids for a WSIB patient.
- Completed by
- Hearing instrument specialist or audiologist, with a physician signature section
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Rapport d'évaluation initiale dans le cadre du Programme de soins musculo-squelettiques
Initial assessment report at the start (block one) of the WSIB MSK program of care for a work-related musculoskeletal injury, including functional abilities.
- Completed by
- Regulated health professional delivering the WSIB MSK program of care (e.g., physiotherapist, chiropractor)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Rapport de mi-parcours dans le cadre du Programme de soins musculo-squelettiques
Mid-point report after block one of the MSK program of care. Not needed if the patient is discharged early.
- Completed by
- Regulated health professional delivering the WSIB MSK program of care (e.g., physiotherapist, chiropractor)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Sommaire des soins et des résultats dans le cadre du Programme de soins musculo-squelettiques
Discharge summary of care and outcomes at the end of block two, or at early discharge, in the MSK program of care.
- Completed by
- Regulated health professional delivering the WSIB MSK program of care (e.g., physiotherapist, chiropractor)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Rapport complémentaire dans le cadre du Programme de soins musculo-squelettiques
Report after an approved supplementary treatment block in the MSK program of care.
- Completed by
- Regulated health professional delivering the WSIB MSK program of care (e.g., physiotherapist, chiropractor)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Rapport sur les services auditifs continus
Report of the minimum ongoing hearing aid services (cleaning, maintenance, etc.) provided during each ongoing-bundle visit.
- Completed by
- Hearing health care provider (audiologist or hearing instrument specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Formulaire de modification du choix de prothèse auditive
Report that hearing aid(s) were returned to the manufacturer and a new device was selected for a WSIB patient.
- Completed by
- Hearing health care provider (audiologist or hearing instrument specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Miniforfait de services auditifs – Rapport des résultats
Outcome report for the mini bundle, e.g., when replacement hearing aids are approved because of a new prescription.
- Completed by
- Hearing health care provider (audiologist or hearing instrument specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Forfait de services auditifs initiaux – Rapport des résultats
Outcome report after delivering the initial hearing services bundle (hearing aid fitting and follow-up).
- Completed by
- Hearing health care provider (audiologist or hearing instrument specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Initial interdisciplinary assessment, including work and job-demand factors, at the start of the WSIB interdisciplinary team program of care.
- Completed by
- Contracted interdisciplinary team (physiotherapist or chiropractor plus occupational therapist, at minimum)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Initial, mid-point, care and outcomes summary and supplementary reports for the WSIB interdisciplinary team program of care, each with a work-hardening version.
- Completed by
- Contracted interdisciplinary team (at minimum a physiotherapist or chiropractor plus an occupational therapist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Formulaire de demande d'exception pour un médicament
Prescriber's request for WSIB coverage of medication outside the WSIB formulary for a work-related injury or illness. Includes opioid dosing and morphine-equivalent questions.
- Completed by
- Medication prescriber (e.g., physician or NP)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French