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.
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.
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.
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.