At the end of block one of the WSIB mild traumatic brain injury program of care, the treating provider files this two-page mid-point report. It compares Patient-Specific Functional Scale scores from the initial assessment with current scores, documents vestibular rehabilitation delivered or planned for block two, and records any recommended referrals, such as the WSIB Community Mental Health Program or the Neurology Specialty Program.
The registered regulated health professional delivering the program, such as a chiropractor, occupational therapist or physiotherapist, completes and signs the report.
Download the current version from the source each time; forms change without notice.
Mild traumatic brain injury program of care: Mid-point report
Rapport de mi-parcours dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères
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The form says it must be completed at the end of block one, the first four weeks of the eight-week program. Submit it online within two business days of the last block one treatment; the fee schedule says the report fee is not paid if the WSIB has not received it within 14 days.
It is short: injured person and provider details, Patient-Specific Functional Scale scores at the initial assessment and mid-point with the relevant physical demands and your assessment of current ability, details of vestibular rehabilitation if provided or planned for block two, and any additional referrals with the reason.
Yes. The French version is the Rapport de mi-parcours dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères (10392B), and the English form notes that it is available in French. Either version is submitted through wsib.ca/submit.