The Saskatchewan Workers’ Compensation Board (WCB) is asking employers to include the following notation on the medical restrictions form (if you use one):
If this form is being used for a work injury at the initial visit, please bill WCB code 640.
Please supply your injured workers with a medical restrictions form. Workers should provide this form to their care provider during their first visit for return-to-work counselling.
This form outlines what the worker can or can’t do at work because of their injury. There are many names that are used to refer to a medical restrictions form. They include:
- Fitness to return-to-work assessment
- Return-to-work template
- Medical absence report
- Physician’s release to return-to-work form
- Medical certificate employee absence-from-work form
- Statement of medical restrictions form
- Functional abilities assessment form
- Medical assessment form
- Health care provider’s assessment for functional abilities
If you do not have a template for this type of form, you can find the WCB’s Medical Restrictions form on the WCB website under Employer Forms & Fact Sheets. The form is also available on the WorkSafe website under Employers and then Return to Work.
If you have questions, please contact the WCB at 1.800.667.7590.