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 Fit For Work Assessment (CL-54)
Clinics assessing a worker for the Workers Compensation Board of PEI use this three-page form to compare the worker's functional tolerances with the reported demands of their job. It records history, chief complaints, a pain rating and daily activities, a musculoskeletal examination, weighted-task and positional tolerances against job demands, a pain and activity screening questionnaire, and summary recommendations.
Who completes it
The clinic-based assessor named in the Assessment completed by field completes and signs the form; the header also names the clinic and the WCB case coordinator.
Submitting and payment
- How to submit it
- Fax the completed assessment to WCB PEI at the number printed on the form; the PDF is fillable, with a Clear Form button.
- Who pays
- Fee code PN 24 is printed in the form's header for billing WCB PEI, which does not post its fee schedule on its forms page.
Good to know
- Weighted tasks cover lifting above and below shoulder and chair to floor, whole-body pushing and pulling, desk-level push and pull, and carrying right, left and bilateral.
- On this form frequent means 33 to 66 per cent of the workday and occasional 1 to 33 per cent; mark a task NR when it is not recommended.
- Positional tolerances for sitting, standing, walking and climbing are recorded beside the job demands for each, so any gap shows on the same line.
- The Functional Scan (CL-53) is a related WCB PEI form for serial scans comparing maximum ability with pre-injury job demands.
Get the official form
Download the current version from the source each time; forms change without notice.
Fit For Work Assessment
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
What does the WCB PEI Fit For Work Assessment measure?
Functional tolerances compared to the reported job demands. Weighted tasks such as lifting, pushing, pulling and carrying are rated at frequent and occasional levels, positional tolerances cover sitting, standing, walking and climbing, and each sits beside the job demand. A musculoskeletal exam and a pain and activity screening questionnaire complete the picture.
Which fee code applies to CL-54?
PN 24, printed at the top of the form next to the clinic name. The header also records the claim number, the worker, the WCB case coordinator, the assessment date and who completed the assessment. The form ends with a summary and recommendations section, then the assessor's signature and date.
How is the Fit For Work Assessment different from the Functional Scan?
The Fit For Work Assessment (CL-54) is a single clinic assessment with history, subjective reports, a musculoskeletal exam and functional tolerances against job demands. The Functional Scan (CL-53) is a grid for up to four serial scans comparing maximum ability levels with pre-injury job demands, billed under PN22 or PN23.