Occupational Therapy (OT) Services Initial Assessment Report Instructions

Provide any additional comments related to the report or treatment.

Provide a comprehensive narrative analysis describing the worker’s recovery, functional status, recovery and return-to-work (RTW) factors, and any RTW considerations or recommendations relevant to planning rehabilitation and workplace re-entry.

Check this box when the referral requires a time-sensitive OT assessment within 6 days to facilitate hospital discharge (applicable to OT–Physical Injury stream only). Fill only if 'OT – Physical Injury (OT-PI)' is 'Yes'.

Check this box when authorizing an OT assessment specifically to determine eligibility or needs for the IHMA program.

Check this box when authorizing an OT assessment specifically to determine eligibility or needs for the PCA program.

Check this box when authorizing an occupational therapy assessment to evaluate the need for ongoing support or services.

Check this box when authorizing both an initial OT assessment and subsequent treatment services.

Check this box when authorizing a different type of OT service not listed above and provide a brief explanation of the specific service required.

Check this box when the assessor determines occupational therapy is not recommended at this time and include an explanation for this decision.

Enter the full name of the claim owner or authorized claimant (first and last name) as it appears on the claim.

Enter the full name of the attending physician responsible for the worker's care, including professional designation if applicable (e.g., Dr. Jane Smith, MD).

Enter any comments about the plan decision (for example: plan approved or declined), including brief details of the outcome, method of communication (phone, voicemail, email), and any relevant notes or follow-up actions. Fill only if 'Other (please explain)', 'Occupational therapy is not recommended at this time (please explain why not)' is 'Yes' on any.

Please enter the full legal name of the company.

Please enter the payee number associated with the company.

Please enter the primary phone number for the company.

Please enter the fax number for the company.

Enter the date the communication occurred (use yyyy-mm-dd) followed by the full name of the WorkSafeBC officer who communicated this decision or information.

Enter the calendar date when the occupational therapy assessment (date of service) took place.

Enter the calendar date on which this assessment report was completed.

Please enter the name of the person providing the signature for the declaration.

Please enter the date the declaration is made.

Enter the recommended rental equipment details including what equipment is needed, the expected rental duration, any follow-up or return-to-work (RTW) plan related to the equipment, and any comparison quote or notes about purchase vs. rental.

Enter the estimated number of rehabilitation worker visit sessions requested for this treatment block.

Enter the estimated number of other sessions (for example, telehealth) requested for this treatment block.

Enter the estimated number of Occupational Therapy (OT) treatment visit sessions requested for this treatment block.

Enter the total number of sessions approved for the treatment block across all listed service types.

Enter the estimated number of OT Return-to-Work (RTW) support sessions requested for this treatment block (used in lieu of in-person OT visits).

Describe any adaptive equipment or aids currently in use in the home (e.g., type of device, make/model if known, quantity, condition, and who provided them).

Describe the worker's home layout, access, safety concerns and any existing modifications or barriers that affect function or mobility (e.g., stairs, narrow doorways, entrances, flooring, bathroom setup).

Check this box if the client has difficulty with, requires assistance for, or is limited in cooking as an instrumental activity of daily living (check all that apply and comment on pre-injury vs. current function).

Check this box if the client has difficulty with, requires assistance for, or is limited in driving or other transportation-related activities (check all that apply and comment on pre-injury vs. current function).

Check this box if the client has difficulty with, requires assistance for, or is limited in household chores (e.g., cleaning, tidying, home maintenance) as an instrumental activity of daily living (check all that apply and comment on pre-injury vs. current function).

Check this box if the client has difficulty with, requires assistance for, or is limited in shopping (e.g., grocery or other shopping) as an instrumental activity of daily living (check all that apply and comment on pre-injury vs. current function).

Check this box if the client has difficulty with, requires assistance for, or is limited in laundry tasks as an instrumental activity of daily living (check all that apply and comment on pre-injury vs. current function).

Check this box if the client has difficulty with, requires assistance for, or is limited in childcare responsibilities as an instrumental activity of daily living (check all that apply and comment on pre-injury vs. current function).

Check this box if the client has difficulty with, requires assistance for, or is limited in volunteering activities as an instrumental activity of daily living (check all that apply and comment on pre-injury vs. current function).

Check this box if the client has difficulty with, requires assistance for, or is limited in school-related activities or participation as an instrumental activity of daily living (check all that apply and comment on pre-injury vs. current function).

Check this box if the client has difficulty with, requires assistance for, or is limited in financial management tasks (e.g., paying bills, budgeting) as an instrumental activity of daily living (check all that apply and comment on pre-injury vs. current function).

Enter the specific 'Other' instrumental activity not listed (e.g., specify the task or activity the worker needs assistance with). Fill only if 'Other' is 'Yes'.

Check this box if another instrumental activity not listed applies, and describe the specific activity and details in the Comments section (check all that apply and comment on pre-injury vs. current function).

Provide any comments about the worker's instrumental activities of daily living, including pre-injury vs. current function, limitations, supports needed, or observations. Fill only if 'Cooking', 'Driving or transportation', 'Household chores', 'Shopping', 'Laundry', 'Childcare', 'Volunteering', 'School', 'Financial management', 'Other' is 'Yes' (any).

Please enter the full mailing address of the provider.

Please enter the city component of the mailing address.

Please enter the province component of the mailing address.

Please enter the postal code component of the mailing address.

Check this box if the worker's ability to move in bed (roll, sit up, reposition) is a relevant mobility issue now or pre-injury and comment on pre-injury vs current function.

Check this box if walking or wheeled mobility (walking, use of cane/walker/crutches, or wheelchair) is a relevant issue now or pre-injury and comment on pre-injury vs current function.

Check this box if transfers (moving between surfaces such as bed, chair, toilet, car) are affected now or were affected pre-injury and comment on pre-injury vs current function.

Check this box if stair climbing is affected now or was affected pre-injury and comment on pre-injury vs current function.

Check this box for any other mobility issues not listed above and describe them in the Comments section, including pre-injury vs current function.

Enter comments describing the worker's mobility (pre‑injury vs current), including details about bed mobility, walking/wheeled mobility, transfers, stair climbing and any other mobility issues or observations. Fill only if 'Bed mobility', 'Walking or wheeled mobility', 'Transfers', 'Stair climbing', 'Other' is 'Yes' (any).

Enter the clinician’s observed and measured objective findings (physical, neurological, cognitive, perceptual, visual, psychological, and any outcome measure results), clearly distinguishing compensable from non‑compensable recovery and return‑to‑work (RTW) factors.

Please enter the full name of the occupational therapist.

Please enter the email address of the occupational therapist.

Describe the occupational therapy plan including recommended length, frequency and duration of visits, involved providers (e.g., rehab worker), specific treatment goals and interventions, follow-up arrangements, any home or equipment needs, and return-to-work considerations or barriers.

Enter detailed recommendations for adaptive equipment, aids, or home modifications (including specific items, rationale, locations in the home, and any installation or sizing notes) that you advise to support the worker's function and safety.

Enter the body area(s) affected and a brief description of the nature or diagnosis of the injury as accepted on the claim.

Enter the date the initial referral was made.

Enter the date when the injury occurred.

Check this box if the report is for an occupational therapy assessment related to a physical injury (OT-PI).

Check this box if the report is for an occupational therapy assessment related to mental health (OT-MH).

Check this box if the report is for an occupational therapy assessment related to a brain injury (OT-BI).

Check this box if the worker currently has limitations with or requires assistance for bathing (e.g., showering, tub transfers) or if bathing function differs from pre-injury status.

Check this box if the worker has difficulty dressing or needs help putting on or removing clothing, or if dressing function differs from pre-injury status.

Check this box if the worker has limitations with eating or feeding themselves (including use of utensils) or if eating function has changed from pre-injury.

Check this box if the worker has difficulty with toileting tasks (toilet transfers, continence management, hygiene) or if toileting function differs from pre-injury status.

Check this box if the worker requires assistance or has limitations with grooming tasks (hair, oral care, shaving, nail care) or if grooming function has changed since pre-injury.

Check this box if the worker has difficulty managing medications (remembering doses, organizing, administering) or if medication management is affected compared with pre-injury.

Check this box when a self-care activity not listed above is affected or requires comment; specify the other activity in the comments field.

Enter any comments about the worker’s current and pre-injury self-care (basic activities such as bathing, dressing, eating, toileting, grooming, medication management or other), describing limitations, assistance required, or changes from baseline. Fill only if 'Bathing', 'Dressing', 'Eating', 'Toileting', 'Grooming', 'Medication management', 'Other' is 'Yes' (any).

Enter the worker’s subjective information including current symptoms, daily functioning, coping strategies, social supports, and results of any administered subjective measures relevant to the assessment.

The anticipated end date of the next treatment block.

The anticipated end date of OT involvement or discharge from OT Services.

Check this box when the worker is currently attached to a job (has a position to which they can return).

Check this box when the worker is not attached to any job or does not have a position to return to.

Check this box when the employer has been contacted about the worker’s case or return-to-work planning.

Enter the date when the employer is expected to be contacted about the worker regarding vocational matters. Fill only if 'Employer contacted' is 'No'.

Check this box when you are providing an anticipated date for contacting the employer, and enter that date in the adjacent field in yyyy-mm-dd format.

Provide a short summary of confirmed job duties, employer contact details and outcomes, job‑attachment or RTW status, and any other notes related to vocational status and employer contact. Fill only if 'Job attached', 'Not job attached', 'Employer contacted' is 'Yes' (any).

Please enter the worker's last name.

Please enter the worker's first name.

Please enter the WorkSafeBC claim number for the worker.

Please enter the worker's middle initial.

Enter the worker's first (given) name exactly as it appears on the claim.

Enter the worker's middle initial as a single letter, if available.

Enter the WorkSafeBC claim number associated with this worker exactly as shown on claim documents.

Enter the worker's last name (surname/family name) exactly as it appears on the claim.

Enter the worker's family or surname exactly as it appears on official records.

Enter the worker's given or first name exactly as it appears on official records.

Enter the worker's middle initial (single letter) if one exists.

Enter the WorkSafeBC claim number assigned to this worker.

Enter the worker's current occupation or job title as a short descriptive string (e.g., Registered Nurse, Construction Labourer, Office Manager).

Provide worker-specific goals to be addressed within the next reporting period (short term).

Enter the worker's specific goals that are to be addressed prior to discharge from OT Services, if different from the short-term goals.