Physicians, nurse practitioners and other health care providers in the Northwest Territories and Nunavut use this two-page report after first treating a work-related injury, and WSCC says the law requires it within three days of the initial visit. Page 1 records subjective and objective findings, diagnosis and treatment. If the worker is not fit for unrestricted work, the Functional Abilities page on the back sets out abilities and restrictions for return-to-work planning.
The attending health care provider completes and signs page 1, and completes and signs the Functional Abilities page whenever the worker is not fit to return to work without restrictions. The worker receives a copy of the Functional Abilities page so the employer can assess suitable modified work.
Enter the worker's last and first name, mailing address with postal code, community, telephone with area code, employer, occupation, date of injury, date of birth and gender (M, F or X). Dates are written month, day, year (MM DD YYYY). The Functional Abilities page repeats the worker's name and adds the claim number, so carry it over if the worker has one.
Print your name, address with postal code and telephone with area code, and the date and time of the exam. WSCC's invoicing FAQ asks that each report include the name of the person you are sending it to and your contact address (email or mail), so complete this block legibly and add the recipient's name when you send it.
Record the worker's description of the injury, then describe their complaints. Keep this separate from your examination findings: WSCC defines objective evidence as visible, measurable findings obtained by a medical examination, tests or diagnostic imaging, and those belong in the Objective section that follows.
Describe objective findings, including any diagnostic results, then the diagnosis and the treatment plan and medication. WSCC can expedite medical referrals, so include recommended investigations, specialist visits and rehabilitation. Answer whether there is a follow-up plan, with its date, and whether factors such as a pre-existing condition may complicate recovery, explaining any yes and attaching details if needed.
Answer yes or no; if no, complete Functional Abilities on the reverse side. Then sign and date, certifying that the report is a correct statement of services you personally rendered. The fillable PDF has to be printed to sign. If you want to speak with a WSCC doctor about the worker, WSCC asks you to say so on the medical report.
Enter the worker's name and claim number. Item 1 grades walking, standing, sitting, lifting floor to waist and waist to shoulder, and stair and ladder climbing, from full abilities to set limits or other. Item 2 marks restrictions: repetitive bending or twisting, work at or above shoulder, chemical or environmental exposure, limited hand use, pushing or pulling, operating motorized equipment, medication side effects (without naming medications) and vibration. Then add comments, how long this applies (1 to 2 days up to 14+ days), whether you discussed return to work, and recommended hours with a start date.
Give the recommended date of the next appointment to review abilities and restrictions, confirm whether you gave the completed Functional Abilities form to the worker and when, and sign. WSCC's return-to-work steps ask you to give the worker this copy so the employer can assess suitable modified work, and to send WSCC both the First Medical Report and the Functional Abilities form.
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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WSCC says the law requires you to report a work-related injury within three days of the initial visit, and its invoicing FAQ asks for the report within three business days of attending the worker. Email or fax it to the NWT or Nunavut claims department, separately from your invoice, which has its own one-year limit.
Whenever you answer No to 'Is worker fit to return to work with no restrictions?' on page 1. Mark the abilities and restrictions that apply, how long they will last (from 1 to 2 days up to 14+ days), recommended hours and start date, and the next review date. Give the worker a copy and send WSCC both pages.
Yes. The form is written for whichever health care provider attends the worker, and WSCC's reporting rules apply to health care providers who treat an injured worker, including physicians and nurse practitioners. Complete the Health Care Provider Information block, then sign the certification that the report is a correct statement of services you personally rendered.
Yes. WSCC publishes the form in English and in French as Premier rapport médical, both as fillable PDFs, and the same CS003 form serves workers in the Northwest Territories and Nunavut. The English form also carries short notes in Inuktitut and Inuinnaqtun, and WSCC has an Inuktitut forms page.