Chiropractor’s Progress/Discharge Report (CHP)

Document type
Downloadable forms
Online submission forms
Customer type
Care providers

This form should be completed after each block of six treatments unless the worker has been discharged, in which case, the CHP should be completed within seven days.

Download

application/pdf — 1.46 MB

Chiropractor’s Initial Report (CHI)

Document type
Online submission forms
Customer type
Care providers

Within three days of beginning treatment, you need to forward this form to the WCB detailing your initial findings.

Download

application/pdf — 1.45 MB

Miscellaneous Billing (MISC)

Document type
Downloadable forms
Customer type
Care providers

Use this form to bill for approved services provided to an injured worker.

Download

application/pdf — 921.96 KB

QuickDASH

Document type
Downloadable forms
Customer type
Care providers

Administer this Functional Outcome Measures self-report tests to WCB customers as soon as possible to measure the worker’s ability to perform certain activities using a hand or arm.

Download

application/pdf — 1.31 MB

Roland Morris questionnaire

Document type
Downloadable forms
Customer type
Care providers

Administer this Functional Outcome Measures self-report tests to WCB customers as soon as possible if the worker is having any difficulty with activities because of back pain.

Download

application/pdf — 469.82 KB

Practitioner’s Return-to-Work (PRTW) Report

Document type
Downloadable forms
Online submission forms
Customer type
Care providers

Once a return-to-work plan has been agreed upon, submit this report to the WCB with copies to the primary care provider, the employer and worker to confirm the hours of work and restrictions.

Fill Out Online

Download

application/pdf — 828.23 KB

Neck disability index (NDI)

Document type
Downloadable forms
Customer type
Care providers

Administer this Functional Outcome Measures self-report tests to WCB customers as soon as possible to measure self-rated disability due to neck pain.

Download

application/pdf — 315.71 KB

Lower extremity functional scale (LEFS)

Document type
Downloadable forms
Customer type
Care providers

Administer this Functional Outcome Measures self-report test to WCB customers as soon as possible if the worker is having any difficulty with activities because of a lower limb problem.

Download

application/pdf — 293.4 KB

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