Physiotherapists and occupational therapists in the Northwest Territories and Nunavut use this two-page report to measure a WSCC claimant's physical abilities against the demands of their pre-injury job. It tracks lifting, carrying, pushing, pulling, standing, sitting, walking and grip strength across up to four test periods, then records work capability, overall progress and the final return-to-work outcome at discharge. Copies go to the physician, the employer and the WSCC.
The physiotherapist or occupational therapist completes the testing and the whole form, initialling each test period, and records whether weights and times were reported by the worker, the employer or another source. The worker and employer do not complete any section.
Download the current version from the source each time; forms change without notice.
Physiotherapy/Occupational Therapy Functional Abilities Report – Form C
Physiothérapie / Ergothérapie Rapport sur les capacités fonctionnelles – Formulaire C
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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Lifting above shoulder, horizontally and floor to waist; carrying with right, left or both hands; pushing and pulling; standing and sitting in minutes; walking distance; and right and left grip strength. A column for pre-injury job demands lets the WSCC compare each result with what the worker's job requires, and other essential job tasks can be added.
The form is marked as copied to the physician, the employer and the WSCC. Its work capability section shows whether the worker can do pre-injury or modified duties in each test period, and when modified duties are selected, the form asks for a return-to-work or stay-at-work plan.
Yes. WSCC publishes CS113 as a fillable PDF in English and in French, and the English form notes that a French version is available. The same form serves workers in both the Northwest Territories and Nunavut, and it sits with Form A (CS111) and Form B (CS112) on WSCC's provider forms page.