Fillable Functional Abilities Form - Wsib (Page 4 of 4) in pdf

Important Information

To receive benefits, the worker must apply for benefits within six months of the date of a work-related injury or illness.

When filing a claim for benefits, the worker must also consent to the disclosure of functional abilities information

provided by a health professional to his or her employer for the purpose of facilitating an early and safe return to work.

Failure to file a claim or provide consent for the release of the functional abilities information can result in no benefits.

If you have questions about the completion of this form please call 1-800-387-0750.

Worker's Responsibilities

•

This form is to be completed by a treating health professional, who will discuss the information with you.

•

Once completed, contact your employer immediately to review the information on the completed form. Together, you

and your employer will begin to plan an early and safe return to work.

Employer's Responsibilities

•

This form provides general information about this worker's functional abilities and restrictions to help you plan an

early and safe return to work.

•

When you provide this form to the treating health professional, ensure that you have the worker's signed consent

(Section B) for the release of functional abilities information.

•

Where available, also attach a description of the worker's job activities to assist the health professional in completing

the form.

•

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. A charge will appear on your

Accident Cost statement or Schedule 2 Invoice which reflects the cost of payment for each form completed.

•

If you have a form that is specific to your workplace and have the cooperation of the worker in providing consent for the

release of information on your form, you may use your own form. If you create your own form, you must reimburse the

health professional directly.

•

Do not send a copy of the completed Functional Abilities Form for Planning Early and Safe Return to Work to the WSIB.

The health professional is responsible for submission of the form.

Health Professional's Responsibilities

•

The employer and worker will use this information to plan the worker's early and safe return to work.

•

Their return to work plans will reflect the functional abilities and restrictions you have noted and presume that no clinical

contraindications exist for other work activities, therefore it is crucial that all sections be completed in full.

•

The completion of this form is based on your examination of the worker and does not require a specialized functional

abilities evaluation.

•

Diagnostic or confidential information must not be included.

•

Please add specific information on the duration of temporary restrictions or maximum times or weights to be considered,

in section E3 under abilities and/or restrictions. If necessary, attach an additional page to this completed form to

describe abilities and restrictions.

•

Completion of this form does not replace clinical reporting requirements to the WSIB.

•

Once you have received this form, promptly complete it and give it to the worker and/or employer.

•

For billing purposes fax or mail pages 2 and 3 to the WSIB. When faxing, do not mail a copy.

The WSIB will pay the health professional for the completed form when pages 2 and 3 are received.

WSIB Fax 416-344-4684

Workplace Safety and Insurance Board

or 1-888-313-7373

200 Front Street West

Toronto ON M5V 3J1

...go to home page

page 4 of 4

2647A4 (07/06)

A guide to completing this form is available at

Functional Abilities Form - Wsib Page 4

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