For workers in the Northwest Territories and Nunavut with a psychological injury, this four-page form translates their condition into workplace terms. If abilities are reduced, the clinician rates 18 behavioural and cognitive abilities, from self-supervision and multi-tasking to memory and computer skills, then marks restricted work settings, shift restrictions, a graduated return-to-work schedule and how long the limitations should last.
The form is addressed to the treating psychologist, who completes and signs sections A to F and gives the worker a copy. The worker and employer do not complete any part, but the employer uses it to plan suitable work.
Download the current version from the source each time; forms change without notice.
Functional Abilities – Behavioural, Cognitive and Emotional
Capacités fonctionnelles – comportementales, cognitives et émotionnelles
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.
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When a psychological condition affects a worker's ability to do their job. If abilities are normal, tick fit for regular duties and sign. If reduced, rate each behavioural and cognitive ability, mark restricted settings and shifts, propose a graduated schedule, estimate how long the limitations will last, and give the worker a copy.
Eighteen scales lettered A to R: self-supervision, supervising others, task persistence, multi-tasking, cooperation, tolerance to confrontation, judgement and accountability, deadlines, attention to detail, distracting stimuli, cognitive demands, emotional situations, reading, writing, numerical skills, communication, memory and computer skills. Several compare the worker with their pre-injury abilities.
Yes. WSCC publishes CS104 as a fillable PDF in English and in French, and the English form notes that a French version is available. It is listed on WSCC's health care provider forms page for both the Northwest Territories and Nunavut, alongside the Psychiatric/Psychological Initial Report (CS103).