F-0043Doctor's first report
Physician's first report: subjective/objective findings, diagnosis, treatment plan and follow-up.
- Completed by
- Physician
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
Yukon WSCB Functional Abilities Form (F-0044)
This one-page Yukon WSCB form sets out an injured worker's functional abilities and restrictions so the employer can keep them at work, or bring them back as soon as it is safe. It is expressly not an off-work note. The provider either confirms no limitations or rates tolerances for walking, standing, sitting, reaching, lifting, hand use, driving, stairs and screen time, with an estimated duration.
Who completes it
The treating health care provider, often the physician, completes and signs it after reviewing it with the worker. The worker receives a copy and shares it with the employer within 24 hours.
Submitting and payment
- How to submit it
- Attach it to the Doctor's First Report (F-0043), or to a progress report when abilities change significantly, and give the worker a copy to pass to the employer within 24 hours.
- Who pays
- WSCB pays health care providers a set amount for functional abilities information given on this board form, while an employer that wants its own form completed must pay for it.
Good to know
- Part B records whether the worker's functional capacity has improved, stayed unchanged or declined since the last visit, so the form can be repeated as recovery progresses.
- Lifting and carrying are rated in bands: up to 5 kg (10 lb), up to 10 kg (20 lb), up to 20 kg (45 lb) or over 20 kg.
- If an employer wants its own functional abilities form completed, it must pay the fee and get the worker's separate consent, because the claim consent covers only board forms.
- You certify that you reviewed the report with the worker and gave them a copy, and you record the date of the worker's next visit.
Get the official form
Download the current version from the source each time; forms change without notice.
Functional abilities form
Fill it with Vero
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.
How this list is checked
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Is the Yukon Functional Abilities Form a sick note?
No. The form states it is not intended to be used as an off-work note. Its purpose is to outline functional abilities and restrictions only, so an employer can accommodate the injured worker to remain at work or, if absence is unavoidable, to return as soon as they can safely do so.
Who gets a copy of the Functional Abilities Form?
The worker gets a copy and is to share it with the employer within 24 hours. WSCB policy 4.4 says functional abilities information goes to the worker, the employer and the board, and is used to develop a return-to-work plan with the worker. You certify on the form that you reviewed it with the worker.
What if the worker has no limitations?
Tick Part A, 'Worker has no functional limitations'. Otherwise use Part C to mark the limitations the employer would need to accommodate, add the estimated duration of functional limitations in days, and use the comments box for specific duty considerations or activities the form does not list.