Medical, physiotherapy, occupational therapy, psychology, dental and massage therapy reports for the Workers' Safety and Compensation Commission, in English and French.
The Workers' Safety and Compensation Commission (WSCC) serves both the Northwest Territories and Nunavut. Physicians, nurse practitioners and other attending providers complete the First Medical Report (CS003), with a Functional Abilities section on the back, then the Medical Progress Report (CS004). Physiotherapists and occupational therapists start with the initial assessment, Form A (CS111), and psychiatrists and psychologists with the Psychiatric/Psychological Initial Report (CS103).
The First Medical Report is due within three days of the first visit. Complete its Functional Abilities section if the worker is not fit for unrestricted work, and give the worker a copy. Several forms print separate fax numbers and email addresses for the Northwest Territories and for Nunavut. Every WSCC form here is published in English and French, and the WSCC also has an Inuktitut forms page. Vero Documents fills the PDF forms from the visit note and the chart, and you review and sign.
CS003Premier rapport médical
Health care provider's first report of a work injury, with a Functional Abilities section on the back.
Rapport médical d'évolution
Health care provider's progress report, with a Functional Abilities section to complete when abilities change significantly.
Rapport médical – Blessures aux yeux
Medical report for a work-related eye injury.
Évaluation du syndrome de vibration des avant-bras
Clinical assessment of suspected hand-arm vibration syndrome (occupational disease).
Capacités fonctionnelles – comportementales, cognitives et émotionnelles
Sets out a worker's behavioural, cognitive and emotional functional abilities and restrictions for return to work.
Demande de prolongation – Physiothérapie et ergothérapie
Physiotherapist's (or OT's) request to extend treatment.
Physiothérapie / Ergothérapie Rapport de congé
Physiotherapist's or OT's discharge report.
Physiothérapie / Ergothérapie Première évaluation – Formulaire A
Physiotherapist's or OT's initial assessment, collaborative treatment plan and work capability.
Physiothérapie / Ergothérapie Rapport d’étape – Formulaire B
Physiotherapist's or OT's progress report.
Physiothérapie / Ergothérapie Rapport sur les capacités fonctionnelles – Formulaire C
Physiotherapist's or OT's functional abilities report for return-to-work planning.
Rapport d’évolution du psychologue
Psychologist's progress report.
Rapport psychiatrique/psychologique initial
Psychiatrist's or psychologist's initial report on a worker.
Massothérapie
Massage therapist's treatment record: treatment dates and response to therapy.
Rapport et estimation – Soins dentaires
Dentist's report of a work-related dental injury and treatment estimate.
CS009Rapport de blessure à la main
Medical report for a work-related hand injury.
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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Within three days of the initial visit. Complete the Functional Abilities section on the back if the worker is not fit for unrestricted work, and give the worker a copy. For follow-up visits, use the Medical Progress Report (CS004) and complete its Functional Abilities section when the worker's abilities change significantly.
Yes. One commission, the WSCC, serves both territories, and this page lists its forms for both. The First Medical Report, the Medical Progress Report, Form A and the massage therapy form print separate fax numbers and email addresses for each territory. Use the ones printed on the form.
Yes. Every WSCC form in this library has a French version, such as the Premier rapport médical (CS003) and the Rapport médical d'évolution (CS004). The First Medical Report also notes, in French, that it is available in French, and it carries a note in Inuinnaqtun and Inuktitut. The WSCC has a separate Inuktitut forms page.
Form A (CS111) for the initial assessment, collaborative treatment plan and work capability, Form B (CS112) for progress and Form C (CS113) for functional abilities for return-to-work planning. To extend treatment, use the Physiotherapy Request for Extension (CS007), and at discharge the Discharge Report (CS008). CS007 and CS008 have no fillable fields.