Physician's report to WCB PEI for a work-related injury: accident description, clinical findings, diagnosis, work capacity and fee codes.
- Completed by
- Physician
- Issued by
- WCB PEI
- Format
- Fillable PDF
- Language
- English
WCB PEI Functional Scan (CL-53)
Treating clinics use this two-page Workers Compensation Board of PEI form to track a worker's functional abilities over time, with columns for up to four dated scans. Each scan rates maximum ability for lifting, carrying, handling, reaching and bending against the pre-injury job demands, flags clinical limitations for sitting, standing and walking, and states whether the worker can do pre-injury or modified duties.
Who completes it
The clinician named in the Completed by field completes and signs the form; pre-injury job demands are recorded as reported by the worker or from an FJA.
Submitting and payment
- How to submit it
- Fax the completed scan to WCB PEI at the number printed on the form; the PDF is fillable.
- Who pays
- Tick fee code PN22 or PN23, or Report Only, at the top of the form when billing WCB PEI, which does not post its fee schedule on its forms page.
Good to know
- Ability levels use F for frequent (34 to 66 per cent), O for occasional (6 to 33 per cent) and R for rare (1 to 5 per cent).
- For sitting, standing and walking, mark whether there is a clinical limitation for return to work and, if so, the safe return-to-work ability.
- Critical job tasks, if applicable, include stair and ladder climbing, crouching or squatting, kneeling and other dated tasks.
- The current version is dated June 2025; the related Fit For Work Assessment (CL-54) is a fuller one-time assessment against job demands.
Get the official form
Download the current version from the source each time; forms change without notice.
Functional Scan
Fill it with Vero
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.
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
How many scans fit on one WCB PEI Functional Scan form?
Four. The grid has dated columns for a first, second, third and fourth scan, each rating maximum ability at frequent and occasional levels, beside the pre-injury job demands reported by the worker or an FJA. Each scan ends with a work capability entry: P for pre-injury duties or M for modified duties.
Which fee codes apply to the Functional Scan?
The form offers three billing choices at the top: PN22, PN23 or Report Only. The header also records the claim number, the worker's name, the clinic, who completed the scan, the worker's job title and the area or areas of injury.
What tasks does the Functional Scan rate?
Lifting from floor to waist, at waist level and above shoulder; carrying with the right, left or both hands; pushing, pulling and grip strength for each hand; above and below shoulder reaching and forward bending; sitting, standing and walking; and critical job tasks such as climbing, crouching and kneeling.