Treating providers in the WSIB mild traumatic brain injury program of care complete this six-page report after the initial assessment of a worker with a concussion or mTBI. It covers who made the diagnosis, injury history, prior concussions, the three most troublesome symptoms, physical findings, the Rivermead questionnaire, Patient-Specific Functional Scale scores, workplace accommodations and the treatment plan. The program runs eight weeks in two four-week blocks.
A registered regulated health professional delivering the program, such as a chiropractor, occupational therapist or physiotherapist, completes and signs the whole report. The mTBI diagnosis itself comes from a physician or nurse practitioner, named in Section C.
Download the current version from the source each time; forms change without notice.
Mild traumatic brain injury program of care (mTBI POC) initial assessment report
Rapport d'évaluation initiale dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères
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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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People with an allowed WSIB claim who are 18 or older, have been diagnosed with a mild traumatic brain injury by a physician or nurse practitioner, and have negative findings on all neuroimaging studies, if any were done. They can enter the program up to three months after the date of injury.
Within two business days of the assessment. The mTBI fee schedule says that if the WSIB has not received a report within 14 days, the report fee is not paid, and block payments are withheld until the WSIB receives the corresponding report. Submit the report through WSIB online services.
The Rivermead Post-Concussion Symptoms Questionnaire, totalled out of 64 excluding other difficulties, and the Patient-Specific Functional Scale for three to five functional activities, at least two of them work-related. Both are available from the WSIB website, and the PSFS is repeated on the mid-point and care and outcome summary reports.