New Brunswick physicians and nurse practitioners use this single report for the first visit after a workplace accident or occupational disease and for every progress visit. Page 1 carries the findings, working diagnosis and treatment plan to WorkSafeNB within 72 hours of the appointment. Page 2 repeats only the functional abilities recommendations, with medical details removed, so the patient can give it to their employer for return-to-work planning.
The treating physician or nurse practitioner completes and signs both pages, ticking a provider type: emergency, family or speciality physician, nurse practitioner, or walk-in clinic. The worker applies separately with an Application for Workers' Compensation Benefits, and the employer files an Employer Report of Injury or Illness.
Tick one of the two boxes at the top of page 1: First Medical Report of Accident or Occupational Disease for the initial visit, or Medical Progress Report for any later visit. WorkSafeNB uses this one form for both. On a progress report you also rate subjective and objective progress as improved, unchanged or regressed in the Provider section, so the reviewer can see how the injury has changed since your last report.
Enter the Medicare number, the WorkSafeNB claim number if known, the visit date and time, the patient's name, sex (male, female or X), date of birth, address, phone, employer and occupation, and the date of incident or of the first report of an occupational illness. Dates run year, month, day. Page 2 repeats this block for the employer, except the Medicare number.
Tick the injury type (acute strain/sprain, fracture, repetitive strain injury, or another injury or illness such as a laceration or psychological injury, specified), any concussion/mTBI features (altered mental state, focal deficit, amnesia, LOC) and the body part with side. Describe the occupational injury or illness with subjective and objective findings, note any other or previous injury contributing to delayed recovery, and give your best working diagnosis, diagnostics ordered (CT, EMG, MRI, X-ray or other, with facility) and treatment plan (chiro, physio, specialist referral, Rx). Attach applicable clinic notes or charts.
Your functional abilities recommendations, repeated on page 2. Tick option 1 if the patient can do usual work duties with no workplace or hour changes. Tick option 2 if they can safely take part in accommodation such as reduced hours, ergonomic changes, tools or aids, or alternative or transitional duties, then mark able or unable for each of the 12 functions, from bend/twist to heavy equipment operation. Record limits such as maximum daily or weekly hours or medication effects under Other limitations, and enter how many days this is valid, up to 14. If unsure of job demands, consult the employer or WorkSafeNB case manager.
Tick your provider type, then enter your WorkSafeNB payee number, provider office service code(s), office address and phone. Print your name, sign and date. By signing you confirm that you believe the injury or illness is consistent with the workplace accident or exposure, attest that the information is accurate and follows best practice standards, and accept that payment depends on legible completion. The form notes that subsection 41(10) of the Workers' Compensation Act authorizes you to release this information.
Page 2 repeats the visit type, patient details and employer note with medical information removed, plus a short guide for the worker on telling their employer and applying for benefits. Sign and date it in its own provider account block, then give it to the patient to provide to their employer. Only page 1 goes to WorkSafeNB.
Download the current version from the source each time; forms change without notice.
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.
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.
Sources for this guide
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WorkSafeNB says physician, nurse practitioner and chiropractor reports are due within 72 hours of the injured worker's appointment, for first reports and progress reports alike. Send page 1 by MyServices secure email, fax, mail or in person. If you fax or email it, do not also mail the original, and make sure the form is complete before you submit it.
Yes. WorkSafeNB introduced the form for physicians and nurse practitioners, and the Provider account section has a nurse practitioner box alongside emergency, family and speciality physicians and walk-in clinics. Enter your WorkSafeNB payee number and provider office service code, print your name, then sign and date both pages.
Only page 2, which the patient gives to their employer. It repeats the patient details, visit type and your functional abilities recommendations, with medical information removed in compliance with New Brunswick's Personal Health Information Privacy and Access Act. The diagnosis, findings and treatment plan stay on page 1, which goes only to WorkSafeNB.
WorkSafeNB asks clinicians not to. Its 2019 redesign removed the question asking whether the patient is able to work. Instead, tick option 1 if the patient can do their usual duties, or option 2 and mark able or unable for each of the 12 listed functions, adding limits such as reduced hours under Other limitations.