What the Doctor First Report is for
WCB Manitoba uses this report to decide whether an injury arose from work and what benefits and treatment follow. WCB’s own fee policy calls it the Doctor Initial Report, Form 4, and the form carries a large 4 in its header. It’s often mixed up with the Manitoba Public Insurance report for motor vehicle injuries. When a worker is hurt driving for work, ask which insurer the claim is with before you choose the form.
Who completes it
The physician who examines the worker completes the whole report, including the worker’s own account of the incident in their words. There’s no part for the worker or the employer to fill in.
How to fill in the report
Worker and employer information
Enter the worker’s name, address, phone, date of birth, gender, weight, height, job title and PHIN, and the claim number if the worker has one. Give the employer’s name and the branch address where the worker is based. The job title lets WCB and the employer compare your restrictions with the work the worker normally does.
Injury details
Give the date of the incident and the area of injury, then the worker’s description of what happened. Record the mechanism as the worker tells it. A clear account helps WCB connect the injury to the work activity.
Examination findings and diagnosis
Enter the examination date, ICD code and diagnosis, then subjective complaints and objective findings. The form asks for range of motion, muscle testing and neurological status, so record measured findings as well as tenderness. Describe any pre-existing condition that may affect recovery, and list tests performed with location and date, attaching results.
Treatment plan
Describe the treatment, medications and referrals, and give the date of the next visit. A next visit date tells WCB when to expect a progress report.
Work capabilities
Say whether the worker will be off work beyond the day of the incident and when they can return to regular duties, or that it’s unknown at the time of the exam. If they can do alternate or modified work, outline the restrictions in functional terms, such as lifting limits or no use of one hand, and give their duration in weeks. “Light duties” alone gives the employer nothing to plan around.
Physician information
Print your name, address, phone and fax, sign and date the report.
Common reasons it’s delayed
- No ICD code or diagnosis.
- Objective findings missing or limited to a description of pain.
- Modified work marked yes with no restrictions or duration.
- Missing PHIN, date of birth or employer.
- An unsigned or undated report.
Submitting and who pays
Fax the report to WCB Manitoba at 204-954-4999 in Winnipeg or 1-877-872-3804 toll free, and attach any test results you list. WCB pays you a reporting fee for the report, at the rate set through its agreements with Doctors Manitoba.