Functional Abilities Form - Wsib
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4Functional Abilities Form
for Planning Early and Safe Return to Work
Health Professionals, please use this form ONLY when requested by an employer or worker.
The purpose of this form is to identify your patient's overall functional abilities and work
restrictions that will assist his/her return to suitable work.
Please promptly complete and return pages 2 and 3 of this form to the worker or employer
to assist the workplace parties in planning an early and safe return to work.
PLEASE ENSURE YOUR BILLING INFORMATION IS NOT GIVEN TO THE WORKER OR EMPLOYER.
Authority to Release Information
Section 37(3) of the Workplace Safety and Insurance Act, 1997 provides the legal authority for health professionals
to give the Workplace Safety and Insurance Board (WSIB), the injured worker and the employer such information as
may be prescribed concerning the worker's functional abilities.
print
black ink
When completing this report, please
in
.
Worker and/or employer should complete Sections A and B of this report. If your patient needs assistance,
please help. Please submit this report even if Section A is not fully completed.
Page 4
Information about your responsibilities can be found on
.
The WSIB will pay health professionals for completing this form.
Mail to:
Fax to:
Workplace Safety and Insurance Board
416-344-4684
OR
200 Front Street West
or 1-888-313-7373
Toronto, ON M5V 3J1
...go to form
A guide to completing this form is available at
print
2647A (07/06)
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