F-0043Doctor's first report
Physician's first report: subjective/objective findings, diagnosis, treatment plan and follow-up.
- Completed by
- Physician
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
Yukon, NWT and Nunavut medical forms for clinicians
All 39 verified territorial forms: WSCC reports for the NWT and Nunavut, Yukon WSCB reports and health referrals, NWT income assistance and student aid forms.
The three territories share a small section of this library: 39 verified forms, mostly workers' compensation. In the Northwest Territories and Nunavut, one board, the WSCC, takes the First Medical Report (CS003) within three days of the first visit and the Medical Progress Report (CS004), both in English and French. Yukon's Workers' Safety and Compensation Board uses the Doctor's first report (F-0043), the Doctor's progress report (F-0042) and a Functional abilities form (F-0044).
Yukon providers must report treatment of a work injury within 2 days and need a service agreement with the board. The NWT's Form D (NWT9386) confirms disability for income assistance, and student aid uses NWT Form G (NWT9008) and Nunavut's FANS form (A-207). Yukon's other forms are mostly referrals, such as hospice and palliative care. The library lists no territorial auto insurance or drug program forms yet. Federal forms such as the T2201, CPP disability and EI certificates apply in the North too; see the federal hub.
Yukon
Professional recommendation supporting extra child care subsidy for a child with special needs.
- Completed by
- 'A qualified professional who can speak to the need(s) of your child, and has the appropriate training and skills to make the recommendation'
- Issued by
- Yukon Education - Early Learning and Child Care (Child Care Subsidy)
- Format
- Language
- English
Referral for admission to a Yukon long-term care home or the community day program.
- Completed by
- Healthcare provider, the applicant, or family/caregiver (referrals accepted from any source)
- Issued by
- Yukon Health and Social Services - Continuing Care
- Format
- Language
- English
Referral from the patient's health-care team for hospice admission in a Yukon continuing care facility.
- Completed by
- Member of the patient's health-care team
- Issued by
- Yukon Health and Social Services - Continuing Care
- Format
- Language
- English
Requests a consultation with the Yukon Palliative Care Resource Team for someone with a life-limiting illness.
- Completed by
- Health care professionals (also family, friends or volunteers)
- Issued by
- Yukon Health and Social Services - Palliative Care Resource Team
- Format
- Language
- English
Provider referral to Yukon Healthy Living programs: Your Health! Your Way!, Diabetes Wellness Series, supervised exercise and Pulmonary Rehabilitation.
- Completed by
- Health care provider
- Issued by
- Yukon Health and Social Services - Chronic Conditions Support Program
- Format
- Language
- English
F-0042Doctor's progress report
Physician's progress report on a worker's recovery.
- Completed by
- Physician
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
Sets out a worker's functional abilities and restrictions so the employer can accommodate an early, safe return to work.
- Completed by
- Health care provider (physician or other treating provider)
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
Hearing service provider's request for prior approval of hearing services or devices on a hearing loss claim.
- Completed by
- Hearing service provider (audiologist / hearing instrument practitioner)
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
Hearing service provider's report on a hearing loss claim.
- Completed by
- Hearing service provider (audiologist / hearing instrument practitioner)
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
Sets out a worker's psychological/cognitive functional abilities and restrictions for return to work.
- Completed by
- Psychologist or other mental health provider
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
Psychologist's progress report.
- Completed by
- Psychologist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
Psychologist's initial assessment report on a worker.
- Completed by
- Psychologist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
Chiropractor's first report and assessment.
- Completed by
- Chiropractor
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
F-0103Dentist's first report
Dentist's first report of a work-related dental injury.
- Completed by
- Dentist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
F-0125Massage Therapy Report
Massage therapist's treatment report.
- Completed by
- Massage therapist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
Chiropractor's progress report.
- Completed by
- Chiropractor
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
Chiropractor's discharge report.
- Completed by
- Chiropractor
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
Physiotherapist's initial assessment, treatment plan and goals.
- Completed by
- Physiotherapist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
Physiotherapist's extension request(s) and discharge report, including return-to-work barriers and recommendations.
- Completed by
- Physiotherapist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
Northwest Territories
CS003First Medical Report
Premier rapport médical
Health care provider's first report of a work injury, with a Functional Abilities section on the back.
- Completed by
- Physician, nurse practitioner or other attending health care provider
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Rapport médical d'évolution
Health care provider's progress report, with a Functional Abilities section to complete when abilities change significantly.
- Completed by
- Physician, nurse practitioner or other attending health care provider
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Rapport médical – Blessures aux yeux
Medical report for a work-related eye injury.
- Completed by
- Treating physician or eye-care provider
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Demande de prolongation – Physiothérapie et ergothérapie
Physiotherapist's (or OT's) request to extend treatment.
- Completed by
- Physiotherapist or occupational therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Language
- English and French
Physiothérapie / Ergothérapie Rapport de congé
Physiotherapist's or OT's discharge report.
- Completed by
- Physiotherapist or occupational therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Language
- English and French
CS009Hand Injury Report
Rapport de blessure à la main
Medical report for a work-related hand injury.
- Completed by
- Treating health care provider
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Massothérapie
Massage therapist's treatment record: treatment dates and response to therapy.
- Completed by
- Registered massage therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Language
- English and French
Rapport et estimation – Soins dentaires
Dentist's report of a work-related dental injury and treatment estimate.
- Completed by
- Dentist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Language
- English and French
Évaluation du syndrome de vibration des avant-bras
Clinical assessment of suspected hand-arm vibration syndrome (occupational disease).
- Completed by
- Physician or assessing health care provider
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Rapport d’évolution du psychologue
Psychologist's progress report.
- Completed by
- Psychologist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Rapport psychiatrique/psychologique initial
Psychiatrist's or psychologist's initial report on a worker.
- Completed by
- Psychiatrist or psychologist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Capacités fonctionnelles – comportementales, cognitives et émotionnelles
Sets out a worker's behavioural, cognitive and emotional functional abilities and restrictions for return to work.
- Completed by
- Treating health care provider (physician, psychologist or other)
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Physiothérapie / Ergothérapie Première évaluation – Formulaire A
Physiotherapist's or OT's initial assessment, collaborative treatment plan and work capability.
- Completed by
- Physiotherapist or occupational therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Physiothérapie / Ergothérapie Rapport d’étape – Formulaire B
Physiotherapist's or OT's progress report.
- Completed by
- Physiotherapist or occupational therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Physiothérapie / Ergothérapie Rapport sur les capacités fonctionnelles – Formulaire C
Physiotherapist's or OT's functional abilities report for return-to-work planning.
- Completed by
- Physiotherapist or occupational therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Formulaire G - Évaluation de l'incapacité
Determines eligibility for the NWT study grant(s) for students with permanent or persistent/prolonged disabilities.
- Completed by
- Qualified practitioner (form says 'i.e. medical doctor')
- Issued by
- NWT Education, Culture and Employment - Student Financial Assistance
- Format
- Fillable PDF
- Language
- Bilingual
Formulaire D - Évaluation de l'incapacité
Medical confirmation of disability for the Income Assistance for Seniors and Persons with Disabilities program; listed with the Income Assistance forms.
- Completed by
- Medical practitioner or nurse practitioner (Section 2); a registered nurse licensed in the NWT only if there is no access to an MD/NP within 3 months (Section 3)
- Issued by
- NWT Education, Culture and Employment - Income Security Programs
- Format
- Fillable PDF
- Language
- English and French
Nunavut
Certifies a permanent disability for the Nunavut Study Grant for Students with Disabilities.
- Completed by
- Certifying medical professional
- Issued by
- Nunavut Department of Education - Financial Assistance for Nunavut Students (FANS)
- Format
- Fillable PDF
- Language
- English
Extended Health Benefits claim with a Record of Appointment(s) that the attending clinician signs to confirm medical appointments, e.g. for EHB-supported medical travel.
- Completed by
- Attending physician or designate, or community health nurse
- Issued by
- Nunavut Department of Health - Extended Health Benefits
- Format
- Language
- English
More Canadian forms
How this list is checked
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.
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Frequently asked questions
Who handles workers' compensation in Nunavut?
The Workers' Safety and Compensation Commission (WSCC) serves both the Northwest Territories and Nunavut with the same forms. The First Medical Report (CS003) is due within three days of the initial visit; complete its Functional Abilities section if the worker isn't fit for unrestricted work, and give the worker a copy. The form lists separate NWT and Nunavut fax and email channels.
When must Yukon clinicians report a work injury?
Within 2 days of treating it. Yukon providers also need a service agreement with the Workers' Safety and Compensation Board. Physicians use the Doctor's first report (F-0043), attach the Functional abilities form (F-0044) and give the worker a copy. The functional abilities form is not an off-work note: it lists abilities and restrictions so the employer can accommodate an early, safe return to work.
Who can complete the NWT income assistance Form D?
A medical practitioner or nurse practitioner completes Section 2 and initials each page. A registered nurse licensed in the NWT may complete Section 3 only if the applicant can't see an MD or NP within 3 months. Send it through the territory's Secure File Transfer service to the regional ECE Service Centre. It's the only clinician form among the income assistance forms, and it comes in English and French.
Is there a disability form for Nunavut student aid?
Yes. The FANS Disability Assessment Form (A-207) certifies a permanent disability for the Nunavut Study Grant for Students with Disabilities. The certifying medical professional completes Sections B and C in full, including the signature, and returns the form to the student, who submits it to FANS. NWT students use Form G (NWT9008), a single bilingual form.