OCCUPATIONAL THERAPY SERVICES

P.O. BOX 2415

EDMONTON, AB T5J 2S5
FAX: 780-427-5863
1-800-661-1993
Provider’s Reference WCB Claim Number
Number [Claim#]
WORKER DETAILS
Surname First Name and Initial Date of Birth (yyyy/mm/dd)
[Surname] [FirstName]
Assessment Date (yyyy/mm/dd) Report Date (yyyy/mm/dd) Date of Accident (yyyy/mm/dd)

Compensable Conditions

Non Compensable Conditions Impacting Return to Work

Service Delivery
In Person Virtual*
*An evaluation was completed via telehealth. Informed verbal consent was obtained from this patient to communicate and provide
care using virtual care and other communication tools. This worker has been explained the risks related to unauthorized disclosure
or interception of personal health information and steps they can take to help protect their information.

REFERRAL QUESTIONS

Details; If none, enter “N/A”

RECOMMENDATIONS

Rationale
Recommendations Recommendation
Must be supported by evidence-based clinical reasoning
Include home equipment Approved by CM:
related to compensable injury.
If none, enter “N/A” Details; If none, enter “N/A” Yes No
If none, enter “N/A” Details; If none, enter “N/A” Yes No
If none, enter “N/A” Details; If none, enter “N/A” Yes No
If none, enter “N/A” Details; If none, enter “N/A” Yes No
If none, enter “N/A” Details; If none, enter “N/A” Yes No
If none, enter “N/A” Details; If none, enter “N/A” Yes No
If none, enter “N/A” Details; If none, enter “N/A” Yes No
If none, enter “N/A” Details; If none, enter “N/A” Yes No

Re-assessment recommended: Yes No N/A Re-assessment date: Date/TBD/N/A

Rationale for re-assessment: Details; If none, enter “N/A”

Case Conference Date: Select date

BACKGROUND INFORMATION

Brief History
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[Surname] [FirstName] [Claim#]

Details; If none, enter “N/A”

Physical and Functional Assessment

Details; If none, enter “N/A”

Worker’s Height: inches Worker’s Weight: lbs

Consistency between functional level and compensable injury/disability? Yes No
If no, explain: Details; If none, enter “N/A”

Aids Currently Used Related to Compensable Injury

Aid Related Activity

Briefly describe how/why aid is used
Briefly describe how/why aid is used
Briefly describe how/why aid is used
Briefly describe how/why aid is used

Living Situation

Type of Residence: Select one If other, specify: If none, enter “N/A”

Ownership: Select one Living Arrangement: Select one

Support

Does the Worker have a caregiver? Yes No

If yes, describe the assistance received: Details; If none, enter “N/A”
Describe any issues with care-giver assistance: Details; If none, enter “N/A”
Does the Worker receive assistance from family or friends? Yes No
If yes, describe the assistance received: Details; If none, enter “N/A”
Did they receive this level of assistance prior to them being injured? Yes No
If no, provide details of what has changed: Details; If none, enter “N/A”

Family Situation

Does the Worker have children? Yes No

If yes, list their age(s):
Are the children dependent? Yes No
If yes, who provides daily childcare?

ACTIVITIES OF DAILY LIVING

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Mobility

Location Independence Level Details

Include assistance required in relation to compensable injury.
Stairs Select one Details; If none, enter “N/A”
Inside the home Select one Details; If none, enter “N/A”
Outside the home Select one Details; If none, enter “N/A”
In/out of bed Select one Details; If none, enter “N/A”
In/out of Select one Details; If none, enter “N/A”
chair/wheelchair
Wheelchair to toilet Select one Details; If none, enter “N/A”
Into shower or Select one Details; If none, enter “N/A”
bathtub
In/out of vehicle Select one Details; If none, enter “N/A”
Other (Specify): Select one Details; If none, enter “N/A”

Toileting

Bowel Routine

Independence: Select one Incontinence: Select one Occurrence: Select one

Specify type of assistance required: Details; If none, enter “N/A”

Bladder Routine

Independence: Select one Incontinence: Select one Occurrence: Select one

Catheter use: No Yes; Describe: Include frequency and type; If none, enter “N/A”
Specify type of assistance required: Details; If none, enter “N/A”

Menstrual Care

Independence: Select one

Specify assistance required: Include frequency and time required; If none, enter “N/A”

Hygiene/Grooming and Skin Care

Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Bathing Select one Details; If none, enter “N/A”
Brushing teeth Select one Details; If none, enter “N/A”
Shampooing Select one Details; If none, enter “N/A”
Brushing/combing hair Select one Details; If none, enter “N/A”
Shaving Select one Details; If none, enter “N/A”
Applying make-up Select one Details; If none, enter “N/A”

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Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Applying deodorant Select one Details; If none, enter “N/A”
Applying Select one Details; If none, enter “N/A”
cologne/perfume
Checking skin Select one Details; If none, enter “N/A”
Applying Select one Details; If none, enter “N/A”
lotions/powder
Other (Specify): Select one Details; If none, enter “N/A”

Comment on tissue or skin integrity issues: Details; If none, enter “N/A”

Dressing

Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Underwear Select one Details; If none, enter “N/A”
Shirt Select one Details; If none, enter “N/A”
Pants Select one Details; If none, enter “N/A”
Socks Select one Details; If none, enter “N/A”
Dresses Select one Details; If none, enter “N/A”
Coats Select one Details; If none, enter “N/A”
Shoes/boots Select one Details; If none, enter “N/A”
Zippers Select one Details; If none, enter “N/A”
Buttons Select one Details; If none, enter “N/A”
Putting clothes away Select one Details; If none, enter “N/A”
Putting on/removing Select one Details; If none, enter “N/A”
glasses
Putting on/removing Select one Details; If none, enter “N/A”
earrings
Putting on/removing Select one Details; If none, enter “N/A”
hearing aids
Other (Specify): Select one Details; If none, enter “N/A”

Nutrition

Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Preparation of simple Select one Details; If none, enter “N/A”
meals
Preparation of main Select one Details; If none, enter “N/A”
meals
Eating Select one Details; If none, enter “N/A”
Drinking Select one Details; If none, enter “N/A”

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Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Meal clean-up Select one Details; If none, enter “N/A”
Other (Specify): Select one Details; If none, enter “N/A”

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (Required for PCA only; If not applicable, delete section)

Transportation

Form of Transportation: Select one If other, specify: If none, enter “N/A”

Vehicle Ownership: Select one Describe vehicle: Year, make, model. If none, enter “N/A”
Are there modifications to the vehicle because of the compensable injury? Yes No
If yes, describe modifications:
Transportation Needs: e.g., work, leisure, appointments, shopping. If none, enter “N/A”
Is the Worker independent in taking public transportation? Yes No
If no, describe how this is related to their compensable injury:
Has their transportation changed since their work-related injury? Yes No
If yes, describe the changes:

Banking/Legal Affairs

Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Banking Select one Details; If none, enter “N/A”
Using an ATM Select one Details; If none, enter “N/A”
Money management Select one Details; If none, enter “N/A”
Writing cheques and Select one Details; If none, enter “N/A”
managing accounts
Legal affairs Select one Details; If none, enter “N/A”
Other (Specify): Select one Details; If none, enter “N/A”

Housekeeping Activities

Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Washing clothes Select one Details; If none, enter “N/A”
Ironing clothes Select one Details; If none, enter “N/A”
Changing or making Select one Details; If none, enter “N/A”
beds
Light household Select one Details; If none, enter “N/A”
cleaning
Heavier household Select one Details; If none, enter “N/A”
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Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
cleaning
Home maintenance Select one Details; If none, enter “N/A”
tasks
Cleaning wheelchair or Select one Details; If none, enter “N/A”
other devices
Shopping Select one Details; If none, enter “N/A”
Grocery shopping Select one Details; If none, enter “N/A”
Putting groceries away Select one Details; If none, enter “N/A”
Other (Specify): Select one Details; If none, enter “N/A”

Recreation

Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Select one Details; If none, enter “N/A”
Select one Details; If none, enter “N/A”

MEDICAL OR PARA-MEDICAL REQUIREMENTS (Required for PCA only; If not applicable, delete section)

Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Dressing changes Select one Details; If none, enter “N/A”
Medication regime Select one Details; If none, enter “N/A”
Exercises Select one Details; If none, enter “N/A”
Orthotics Select one Details; If none, enter “N/A”
Ordering Select one Details; If none, enter “N/A”
supplies/equipment
Maintain Select one Details; If none, enter “N/A”
supplies/equipment
Other (Specify): Select one Details; If none, enter “N/A”

PSYCHOLOGICAL/COGNITIVE FUNCTIONING (Required for PCA only; If not applicable, delete section)

Mental Status

Details; If none, enter “N/A”

Cognitive Status

Details, i.e., objective observations of cognitive abilities. If none, enter “N/A”

Worker oriented to person/place/time? Yes No

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If no, describe: Details; If none, enter “N/A”

Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Planning and Select one Details; If none, enter “N/A”
organizing
Comprehension Select one Details; If none, enter “N/A”
Ability to initiate Select one Details; If none, enter “N/A”
Insight Select one Details; If none, enter “N/A”
Problem solving Select one Details; If none, enter “N/A”
Decision making Select one Details; If none, enter “N/A”
Attention/Concentration Select one Details; If none, enter “N/A”
Other (Specify): Select one Details; If none, enter “N/A”

Are there safety concerns? Yes No

If yes, describe: Details; If none, enter “N/A”
Is supervision required? Yes No
If yes, describe: Include level of supervision; If none, enter “N/A”
Is the Worker capable of self-managed care? Yes No
If yes, describe: Indicate additional training or community support needed; If none, enter “N/A”
If no, describe: Indicate if and why Worker needs to be monitored; If none, enter “N/A”

Communication

Details
Activity Independence Level Include assistance required in relation to compensable injury,
as well as frequency and time required.
Speech Select one Details; If none, enter “N/A”
Word finding Select one Details; If none, enter “N/A”
Writing Select one Details; If none, enter “N/A”
Reading Select one Details; If none, enter “N/A”
Computer literacy Select one Details; If none, enter “N/A”
Other (Specify): Select one Details; If none, enter “N/A”

VOCATIONAL (Required for PCA only; If not applicable, delete section)

Is the Worker employed? Yes No

Is the Worker engaged in productive behaviour (e.g., school volunteer, etc.)? Yes No
If yes, describe: Details; If none, enter “N/A”
Is the Worker interested in expanding their vocational options? Yes No
If yes, describe: Details; If none, enter “N/A”
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Is the Worker attending classes? Yes No

If yes, describe: Provide class/program details; If none, enter “N/A”
Comment on any barriers to the above: Details; If none, enter “N/A”

Access to Details
Activity Independence Level Include assistance required in relation to compensable
Device injury, as well as frequency and time required.
Computer use Select one Select one Details; If none, enter “N/A”
Smartphone use Select one Select one Details; If none, enter “N/A”
Other (Specify): Select one Select one Details; If none, enter “N/A”

ADDITIONAL INFORMATION

Details; If none, enter “N/A”

REPORTING TIMELINE
Was this report completed and submitted within five (5) business days: Yes No
If no, provide details as to why:

If you have any questions regarding the information or would like to discuss, please contact the undersigned.

Therapist’s Name Telephone Number Date (yyyy/mm/dd)

Occupational Therapist

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APPENDIX

Medication/Medication Management Record

Medication (incl. OTC) Dosage Frequency Doctor’s Name and Phone Number

Comment on overall ability to management medication (include obtaining prescriptions, safety, compliance,
abuse).

Details; If none, enter “N/A”

Daily Report

Please indicate general occurrences for each hour. Include meals and amounts, bowel movements, sleep,
procedures, therapies, recreation activities, baths, bed changing, medical or behavioral events, and so forth.
There is room at the end to add comments or elaborate on an event.

Time Activities Time Activities

5:00 am 5:00 pm
6:00 am 6:00 pm
7:00 am 7:00 pm
8:00 am 8:00 pm
9:00 am 9:00 pm
10:00 am 10:00 pm
11:00 am 11:00 pm
12:00 pm 12:00 pm
1:00 pm 1:00 am
2:00 pm 2:00 am
3:00 pm 3:00 am
4:00 pm 4:00 am

Comments: Details; If none, enter “N/A”

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PHOTOS (IF APPLICABLE)

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