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WSCC Medical Report Eye Injuries (CS005): NWT, Nunavut

The WSCC uses this two-page report when a worker in the Northwest Territories or Nunavut is treated for a work-related eye injury. It records which eye was hurt, visual acuity at the first examination before treatment, the worker's account of the cause, and findings drawn on a diagram after fluorescein. The provider also states complications, probable permanent disability, hospital care and the worker's current ability to work.

Who completes it

The health care provider who examines or treats the injured eye completes and signs both pages, including the worker information block, claim number and their WSCC supplier billing number. 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, as printed on the form; the Workers' Compensation Acts quoted on page 2 require the report within three days after the examination or treatment.
Who pays
Page 2 has lines for your WSCC supplier billing number, fee codes, fees submitted and the report form fee, and WSCC pays medical invoices submitted within one year of the service.

Good to know

  • Question 12 grades work ability using National Occupational Classification categories: Limited (loads up to 5 kg), Light (5 to under 10 kg), Medium (10 to 20 kg) and Heavy (over 20 kg).
  • Modified duties need a duration (1 to 7, 8 to 14 or 15 to 21 days, or more) and a start date; dates on this form are written year, month, day.
  • Question 1 asks whether you want a WSCC doctor to contact you, and question 9 asks for particulars of any previous disease or injury in either eye.
  • If a health care facility employs you, the Acts make the facility responsible for making sure the report is submitted; the regulations set a penalty for failing to provide required information.

Get the official form

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

Medical Report Eye Injuries

Rapport médical – Blessures aux yeux

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.

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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.

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Frequently asked questions

What does the WSCC eye injury report ask for?

Which eye was injured, visual acuity in each eye at your first examination and before treatment, what the worker said caused the injury, and findings marked on right and left eye diagrams after fluorescein. It also asks about treatment, previous eye disease or injury, expected complications, probable permanent disability, hospital care and current work ability.

How soon must the eye injury report reach WSCC?

The Nunavut and NWT Workers' Compensation Acts excerpt printed on the form says a health care provider's report must be submitted within three days after the examination or treatment. Email or fax it to the NWT or Nunavut claims department, using the contact details printed on the form.

Is the WSCC eye injury form available in French?

Yes. WSCC publishes CS005 as a fillable PDF in both English and French, and the English form notes that a French version is available. The same form serves workers in both the Northwest Territories and Nunavut, because one commission covers both territories, and the current printed revision is CS005 0924.