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WSCC Hand Arm Vibration Syndrome Form (CS057)

When a worker in the Northwest Territories or Nunavut may have hand-arm vibration syndrome, the WSCC uses this two-page assessment to document it. The provider records symptoms and clinical findings in three areas: peripheral vascular, peripheral neurological, and extremity musculoskeletal and skin. Five history questions cover concurrent disease, tobacco use, medication and herbal remedies, family history of Raynaud's, and vibration exposure outside work.

Who completes it

The assessing health care provider completes and signs the whole form, printing their name and WSCC supplier billing number and the worker's details and claim 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 Acts excerpt on page 2 requires a provider's 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

  • Vascular findings cover reactivity, timing, duration and sites, plus pulses, colour, trophic changes and edema; neurological findings cover sensory and motor testing and reflexes.
  • The musculoskeletal and skin section asks about power, skin colour and temperature, with range of motion, atrophy and edema as clinical findings.
  • History questions also cover vibration exposure in non-occupational settings and family history of Raynaud's disorder, alongside tobacco use, concurrent disease and current medications.
  • If a health care facility employs you, the Acts make the facility responsible for getting the report submitted; the printed revision is CS057 0924.

Get the official form

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

Hand Arm Vibration (HAV) Syndrome Assessment Form

Évaluation du syndrome de vibration des avant-bras

Official pagePDFVersion française

Fill it with Vero

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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 HAV syndrome assessment form cover?

Three assessments, each with symptoms and clinical findings: peripheral vascular (pulses, colour, trophic changes, edema), peripheral neurological (sensory and motor testing, reflexes) and extremity musculoskeletal and skin (range of motion, atrophy, edema). It also asks five medical history questions, including tobacco use, medications and herbal remedies, and vibration exposure outside work.

How soon must the HAV assessment reach the WSCC?

The excerpt from the Nunavut and Northwest Territories Workers' Compensation Acts 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, and send any invoice separately to Financial Services.

Is the HAV syndrome assessment form available in French?

Yes. WSCC publishes CS057 as a fillable PDF in English and in French, as Évaluation du syndrome de vibration des avant-bras, and the English form notes that a French version is available. The same form serves workers in the Northwest Territories and Nunavut.