Physiotherapists and occupational therapists in the Northwest Territories and Nunavut report their first assessment of a WSCC claimant on this two-page form. It captures the diagnosis by body part with expected recovery based on the Medical Disability Advisor (MDA), significant subjective and objective findings, employer contact, expected return-to-work dates, and a job match comparing pre-injury demands with present capability. Page 2 sets out a collaborative treatment plan.
The physiotherapist or occupational therapist completes the whole form, entering the provider name, practitioner name and ID number, the worker's family physician and the employer's contact details. The worker and employer do not complete any part.
Download the current version from the source each time; forms change without notice.
Physiotherapy/Occupational Therapy Initial Assessment – Form A
Physiothérapie / Ergothérapie Première évaluation – Formulaire A
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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Form A asks for a Medical Disability Advisor (MDA) diagnosis, specifying the body part, and an expected recovery date based on the MDA. It also asks whether the injury is a sprain or strain, and whether any flags or indicators influence the expected duration, with an explanation if they do.
Page 2 has rows for up to three goals, each with the methodology you will use and a recommended time frame with from and to dates. A further box covers additional requests or recommendations. Progress against these goals is then reported on Form B, the Physiotherapy/Occupational Therapy Progress Report.
Yes. WSCC publishes CS111 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 the Northwest Territories and Nunavut, and the matching French Form B and Form C are published alongside it.