An occupational therapist or registered nurse uses this assessment to record the attendant care a person needs after an Ontario car accident, in minutes and times per week across three levels of care. Part 4 turns that time into a monthly attendant care benefit using the hourly rates for the accident date, and the insurer must respond within 10 business days.
An occupational therapist or registered nurse, called the Assessor, completes all five parts and signs Part 5, using insurance details the applicant provides. The adjuster completes the insurer's box to approve, partially approve or not approve the assessment.
Enter the applicant's details, the claim number, policy number or both, and the insurer and policy holder as the applicant provides them. Fields marked * are required if known, ** need at least one entry and *** are optional. In HCAI, choose the licensed insurer rather than an independent adjusting firm, and enter the policy holder's last name when the applicant is not the policy holder.
Give the date of this assessment, whether it is the first assessment of this applicant (if not, the date of the last one) and the current monthly allowance if known. Then add the assessor's name, profession and College registration number, and the facility's HCAI Facility Registry Number and FSRA licence number if applicable. HCAI requires assessment dates on or after the accident date and no later than the submission date.
Level 1 is routine personal care. For each activity the applicant needs, estimate the minutes it takes and the times per week, then multiply for total minutes per week: dressing and undressing the upper and lower body, prosthetics, orthotics, grooming (face, hands, shaving, cosmetics, hair and nails), feeding, mobility and transfers, and extra laundering due to incontinence or spillage. Leave unneeded activities blank and carry the Part 1 total to Part 4.
Level 2 covers basic supervisory functions: hygiene (cleaning the bathroom after use, changing bedding and making the bed, clothing care), and basic supervisory care where the applicant cannot reattach tracheal tubing, needs help with transfers, turning or genitourinary care, cannot get in and out of a wheelchair or handle an emergency, or needs custodial care because of behaviour changes. Co-ordination of attendant care is capped at one hour per week.
Level 3 is complex health care and hygiene: genitourinary and bowel care, tracheostomy and ventilator care, prescribed exercise and walking with aids, skin care, oral, injected and inhaled medication, bathing and oral hygiene, other therapy such as TENS or dorsal column stimulation, maintaining supplies and equipment, and skilled supervisory care for violent behaviour that may cause physical harm. Record minutes and frequency for each and carry the total to Part 4.
The assessor must complete this part. For each level, divide total minutes per week by 60, multiply by 4.3 for monthly hours, then multiply by the hourly rate: the printed rates for accidents from March 31, 2008 to August 31, 2010, or the rates in FSRA's guideline under SABS s. 19(2)(a) for later accidents, matched to the accident date. The sum is the Total Assessed Monthly Attendant Care Benefit, subject to SABS limits.
The assessor confirms the information is accurate and that appropriate consent was obtained from the applicant. In HCAI the form cannot be submitted unless the signature is on file; the signed paper copy stays at the facility, and the insurer or FSRA may ask for it. If there are attachments, tick the box, give the number and send them directly to the insurer. The adjuster then approves, partially approves or does not approve.
Download the current version from the source each time; forms change without notice.
Assessment of Attendant Care Needs
Évaluation des besoins des personnes soignantes modifiée
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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Only an occupational therapist or a registered nurse, whom the form calls the Assessor; the SABS requires one of them to prepare and submit it. In HCAI, the assessor must be registered with the submitting facility, and the form cannot be submitted unless their signature is on file. The assessor gives copies to the applicant and the applicant's health practitioner.
For each level, total weekly minutes are divided by 60 and multiplied by 4.3 to get monthly hours, then by that level's hourly rate (A, B or C). For accidents on or after September 1, 2010, the rates come from FSRA's attendant care rate guideline for the accident date. The three amounts add up to the Total Assessed Monthly Attendant Care Benefit, subject to SABS limits.
Whenever changes would affect the amount of the benefit, and within 15 business days when the insurer asks for one; the insurer keeps paying at the same rate until it arrives. More than 104 weeks after the accident, a new Form 1 can't be required or submitted unless 52 weeks have passed since the last insurer examination on attendant care.
Yes, for facilities registered with HCAI: FSRA's HCAI Guideline requires Form 1 to go to HCAI rather than directly to the insurer, with attachments sent to the insurer separately. Approved attendant care services can then be billed in HCAI on the Attendant Care Services Invoice (ACSI), which references the Form 1 document number.