Initial, progress or discharge report for clinic-based occupational rehabilitation (CBOR) of a worker.
- Completed by
- Attending licensed practitioner at a clinic-based occupational rehabilitation provider
- Issued by
- WorkplaceNL
- Format
- Language
- English
WorkplaceNL Hand Injury Report (Form 53)
WorkplaceNL asks an injured worker to have their treating health care provider complete this one-page hand form and return it. It records which hand is injured and which is dominant, any previous defect, and on a diagram the site of amputations, joints with permanently restricted motion and joints permanently ankylosed, then the degrees of utmost flexion and lack of extension for each damaged joint.
Who completes it
The treating health care provider completes and signs the form, certifying it is complete and accurate. The worker brings it to their provider, and the worker's details, including claim number and MCP number, go at the top.
Submitting and payment
- How to submit it
- Return it to WorkplaceNL by fax, toll-free fax, mail or drop-off in person.
- Who pays
- The form has no fee or billing section; WorkplaceNL physicians invoice on the physicians' invoice, Form 92.
Good to know
- Mark amputations with straight lines showing site and direction, circle joints with permanently impaired motion, and put an X over joints permanently ankylosed.
- The form lists normal flexion as 70 degrees at the DIP, 100 at the PIP and 90 at the MCP, and asks for each finger's utmost flexion and lack of extension.
- Detail thumb restrictions in adduction, abduction and opposition, and other impairments such as cold sensitivity, altered sensation, swelling or tissue loss.
- Say what further improvement you expect and, if any, when maximum recovery should be reached; the current version is dated January 2019.
Get the official form
Download the current version from the source each time; forms change without notice.
Hand Injury (Form 53)
Fill it with Vero
If your copy of the form is a fillable PDF, upload it 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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Who completes WorkplaceNL Form 53?
The worker's treating health care provider. The form tells the worker to ask their treating provider to complete it and return it to WorkplaceNL. The provider signs, prints their name and dates it, certifying that the report is complete and accurate.
How are joint ranges recorded on the WorkplaceNL hand form?
For each joint permanently damaged by the injury, record in degrees the position of utmost flexion and the lack of full extension, finger by finger for the little, ring, middle and index fingers and the thumb. Normal flexion is printed for reference: DIP 70, PIP 100 and MCP 90 degrees.