WorkSafeNB requires this booklet for ketamine or esketamine treatment on a claim. The treatment provider submits a pre-approval request before treatment is authorized, completes a monitoring section after every session, and sends long-term reports with PHQ-9 scores at baseline, 4 to 6 weeks, 3 months, 6 months and 9 months. Approved requests receive a WorkSafeNB reference number.
The treatment provider completes all sections; the session checklist and psychological monitoring log are completed by the treating nurse or physician, and an airway management expert is named for each session.
Download the current version from the source each time; forms change without notice.
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Complete the Pre-Approval Request Section and submit it before treatment. Its checklist requires an accepted compensable injury, DSM-5-TR major depressive disorder, no exclusion criteria, a statement of safety if applicable, and a treatment and monitoring plan aligned with WorkSafeNB and billing standards. Approval comes with a reference number.
After every session in the Monitoring and Reporting Section, and in the Long-Term Reporting Section at baseline, 4 to 6 weeks, 3 months, 6 months and 9 months, with the PHQ-9 attached. WorkSafeNB describes ongoing monitoring and quarterly reviews to evaluate safety and efficacy.
Yes. WorkSafeNB publishes a French version, Examen de la thérapie par la kétamine, on its French-language site. The English booklet is in WorkSafeNB's general forms list under health care rather than on the health care forms page.