Wsib functional abilities form pdf

Progress report pdf 0041a continuity report pdf 2232a functional abilities form for early and safe return to work pdf 2647a guide to completing the functional abilities form. By signing a form 6, you allow your doctor to complete the functional abilities form and provide a copy of the completed form to you, your employer, and the wsib. Functional abilities form schedule 2 employers group. Wsib form 6 workers report of injurydisease, form 7 employers report of injurydisease and the wsib faf form functional abilities form for early and safe return to work. Health professionals report form 8 health professional, please use this form for. If you have not already reported the details of this claim to your employer, please.

Please complete this form to assist us in determining your patients eligibility for sick leave due to total disability. A claim for wsib benefits requires completing four forms. Wsib ontario faf functional abilities form for planning early and safe return to work print modified on. A functional abilities form faf will not be paid if completed on the same date. You can order some of these guides, publications and forms online and have them mailed to you through our order wcb forms page. The lefs can be used by clinicians as a measure of patients initial function, ongoing progress and outcome, as well as to set functional goals. Due to scheduled maintenance, all of our online services will be unavailable on sunday, april 19 from 6. Consult the guide for obtaining information for health care practitioners in cases of employee illness or injury for more information on when and how to use this form. Many workplaces have developed their own unique functional abilities forms for workers to bring to their healthcare providers. The wsib will pay health professionals for completing this form. Functional abilities form this form, when completed, is. Functional abilities form for timely return to work. Eiher you or your employer may request this information by using the wsib s functional abilities form for planning early and safe return to work.

The interpretations are not injury risk thresholds. The purpose for this form is to provide the board with information to assess whether you are able to perform the essential duties of your position, and understand your restrictions andor limitations to assess workplace. Health professionals progress report form 26 view only pdf 0896a health professional continuity report form reo8 pdf 2234a. Wsib functional abilities form university of guelph. Insurance wsib with information about my functional abilities on the this form created by my employer. Wsib form 6 and functional abilities form instructions for completion if you are using this 9 nine page package, you have sustained a workplace injury in the course of duty that requires medical assessmenttreatment. The functional abilities form for a timely return to work is completed in part by the employer or the worker and in part by the health care professional.

Ergonomics guidelines identified in italics and listed as. This ensures that the worker consents to and understands the reason why the faf information will be shared with the employer and the wsib. This can provide the employer with information to clarify the workers functional capabilities and assist in the development of a return to work plan for small. This form, when completed, is used to enable an employer to accommodate an ill or. If we require further clarification regarding your patients fitness for work or you are reporting that your. The faf can be used as a tool to facilitate return to work discussions between the employer and the injuredill worker.

By completing this functional abilities form, the information contained herein will become part of the employee health file and may be accessed by the patient injured worker, wsib wcb cnesst, insurance company, third party administrator, or other health. Do have your doctor file a functional abilities form faf for an early and safe return to work whenever. If you are indicating that your patient is totally unfit for any work including nonsafety sensitive, sedentary officetype duties. The wsib will not pay for the employergenerated form. Wsib ontario faf functional abilities form for planning.

This form is reproduced by the wsib system navigator with all fields open for entry except the date of injury. If either or both of these forms are received by wsib. Abilities form faf will not be paid if completed on the same date. Proposed interpretations for wsib functional abilities form. A members guide to the workplace safety and insurance. Form 6, 7, 8 and the functional abilities form throughout the claim process it is important that copies of completed forms and notes on any correspondence are kept so that you have a detailed record of your communication with not only the wsib but also, your employer and health. It is important for the employer to explain to the worker that the shared information pertains only to hisher functional abilities as outlined on the form. Complete required fields, edit, sign, save or print your form. Functional abilities form for planning early and safe return to work. Completing the form give a copy of page two only to your patient to give to employer please send pages one and two to the workplace safety and insurance board. The form provides an avenue for healthcare professionals to outline the workers abilities and prognosis. The lower extremity functional scale lefs is a questionnaire containing 20 questions about a persons ability to perform everyday tasks.

Commonly used forms form 8, form cms8 and faf wsib. Health professionals report form 8 pickering wellness. The prescribed form that is available from the wsib is a generic form developed to assist with general functional abilities information the wsib will pay the health professional to complete the prescribed wsib form only. Find the appropriate forms to submit your claims or to update your information for your manulife investment, insurance, benefits, or pension accounts. Patients who are claiming benefits under the wsib insurance plan for an injuryillness related to work, or you think that the cause of your patients injuryillness is workplace factors. If you are under the age of 16 you need your parent or guardians signature to permit the release of your functional abilities. The prescribed form that is available from the board is a generic form developed to assist employers with general functional abilities information and consent by the injured worker. It is an offence to deliberately make false statements to the workplace safety and insurance board. Complete at the end of the history and prior to physical examination. These are the key wsib forms that members can downloaded to speed up the registration of a claim, release of functional abilities information, expense forms, including the direction of authorization that enables the union to legally represent members at the wsib.

The following interpretations were derived through a synthesis of many research sources, which are listed at the end of this document. A functional abilities form for early and safe return to work 370k, pdf is an optional form designed to help workers and employers meet their returntowork obligations. The following dos and donts are intended as a guide to minimize problems that unionized members may. On the workers initial visit, only the form 8 will be paid. Functional abilities form for timely return to work atworkcanada. Mental illness, ptsd andor mild traumatic brain injury mtbi. The patientspecific functional scale this useful questionnaire can be used to quantify activity limitation and measure functional outcome for patients with any orthopaedic condition. Your patient and their employer will use this information as a tool for planning a return to suitable work. Functional abilities form and guide unifor local 199. Guide to completing the functional abilities form wsib. By signing a form 6, you allow your doctor to complete the functional. Any dispute about your functional abilities must be resolved by the wsib see section 118 of the wsia. The wsib will pay the health professional to complete the prescribed form only.

Functional abilities form functional abilities form for timely return to work. Functional capability forms workers compensation board. Health professionals will be supplying your employee with a copy of page three of the form 8. Download the functional abilities form pdf, 93 kb section a employees information to be completed by the employees supervisor employee name. Generally, the wsib will pay no more than two weeks of benefits to a worker who has not signed a form 6. Functional abilities information may be indicated on a wsib functional. Functional abilities form this form, when completed, is used to enable an employer to accommodate an ill or injured employee to remain at, or if absence is unavoidable, to return to work as soon as they are safely able to do so. This can provide the employer with information to clarify the workers functional capabilities and assist in the development of a rtw plan. Healthcare providers typically request a fee to complete functional capability forms.

Employer should give you a copy of form 7, in addition a functional ability form faf, and perhaps a form 8 for the health care practitioner to fill out. Proposed interpretations for wsib functional abilities. If there is no pda available for the job, the employer may wish to use the wsibs physical demands information form pdif available on the wsib website under. You are required to complete these forms in order to establish a claim with wsib and receive benefits to assist in your recovery. Delay in completing the form 2647a can result in a barrier to the return to work process. Functional abilities information does not include details about your medical condition. Functional abilities form for early and safe return to work pdf 2647a guide to completing the functional abilities form pdf fee schedule for the updated faf fee. Safety critical positions are mandated by transport canada. Your employer only needs to report your accident to the w sib if you lose time from work due to the injury or if the injury necessitates medical attention or some form of health care, i. If the worker or employer has given you a wsib functional abilities form faf to complete at the same time as you are filling out the form 8, you do not need to answer questions e3 e4 e5. A functional abilities form for early and safe return to work 370k, pdf is an optional form designed to help workers and employers meet their returntowork. Wsib entitlement provides for two forms of compensation in the event of a workplace injury. Functional abilities form faf a functional abilities form faf for early and safe return to work pdf provides information about your patients abilities. If you are indicating the patient is unable to return to work at this time, please provide an explanation in the space provided with question e3.

The wsib will pay the health professional to complete the prescribed wsib form only. Occupational disease and survivors benefits program. The prescribed form that is available from the wsib is a generic form developed to assist with general functional abilities information. Functional abilities forms workers compensation board of. We recommend that you save a copy of the pdf form for your records unless you are using a.