Try for free

WSCC Medical Progress Report (CS004): NWT and Nunavut

Physicians, nurse practitioners and other attending providers in the Northwest Territories and Nunavut use this two-page report at follow-up visits on a WSCC claim, after the First Medical Report (CS003). Page 1 records any change in diagnosis, subjective complaints, objective findings, treatment, investigations, specialist referral and the follow-up date. When the worker's abilities have changed significantly, the Functional Abilities page on the back updates restrictions for return-to-work planning.

Who completes it

The attending health care provider completes and signs page 1 and, when abilities have significantly changed, the Functional Abilities page, giving the worker a copy of that page. The worker and employer do not complete any section.

Submitting and payment

How to submit it
Email or fax it to WSCC's NWT or Nunavut claims department, depending on where the worker is, within three business days of the visit as WSCC's invoicing FAQ asks. Send any invoice separately to Financial Services.
Who pays
Bill on the WSCC Medical Invoice form, sent to Financial Services separately from the report within one year of the service, since WSCC returns invoices in other boards' formats.

Good to know

  • Tick 'Refer to WSCC Medical Advisor?' to speak with a WSCC doctor; WSCC says the case manager then asks the Medical Advisor to contact you.
  • If you refer to a specialist, the form asks whether you will arrange it and what type; WSCC says its Medical Unit can usually expedite specialist appointments and diagnostic imaging.
  • The Functional Abilities page grades walking, standing, sitting, lifting and climbing, marks restrictions such as vibration exposure, and asks for medication side effects without naming the medications.
  • The printed revision is CS004 0824, and one form serves both territories; the page footer lists the Yellowknife and Iqaluit offices that receive reports.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Progress Report

Rapport médical d'évolution

Official pagePDFVersion française

Fill it with Vero

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.

See how Vero Documents works

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

When do I fill in the Functional Abilities page of the Medical Progress Report?

Only when the worker's abilities have significantly changed since the last report. Mark current abilities and restrictions, how long they will apply (1 to 2 days up to 14+ days), recommended hours and start date, and the next review date. Confirm you gave the worker a copy, then sign the page.

How fast must the WSCC Medical Progress Report be sent?

WSCC's invoicing FAQ asks for medical reports within three business days of attending an injured worker, sent separately from the invoice. Email or fax the report to the NWT or Nunavut claims department, and include the name of the person you are sending it to and your contact address.

Is the WSCC Medical Progress Report available in French?

Yes. WSCC publishes it in English and in French as Rapport médical d'évolution, both as fillable PDFs on its health care provider forms page, and the English form notes that a French version exists. The same CS004 form is used for workers in the Northwest Territories and Nunavut.