What Form E is for
Form E is one of the WCB forms for out-of-province clinics, alongside Form B for the initial assessment and Form C for progress reports. Each column is a testing period, so a single form shows the trend from the first assessment to discharge. The last column holds the pre-injury job demands, which is what WCB compares the results with.
Who completes it
The treating provider at the approved clinic completes it, such as a physiotherapist, and initials each tested period. There’s no worker section. The worker’s physician gets a copy but doesn’t complete it.
How to fill in the report
Worker and provider information
Enter the claim number, date of initial assessment, health card number, worker’s name, area and type of injury, and the employer with a contact name and phone. Add the provider and practitioner names, ID number, phone and fax.
Physical abilities assessment
Choose pounds or kilograms, then for each period enter the test date and the weights for lifting above shoulder, horizontal and floor to waist, carrying with each hand and both, pushing and pulling, at frequent and occasional levels. Fill in the pre-injury job demands column and say whether the worker, the employer or someone else reported them. The form refers to WCB’s Work Capabilities definitions for these terms.
Tolerances and grip
Record standing, sitting and walking tolerances and mark each as reported by the worker or observed during assessment. Give right and left grip strength. Add other essential or critical job tasks.
Work capability and progress
For each period, mark whether the worker can do pre-injury job duties or transitional duties, and whether overall function is improving, unchanged or declining. Initial each period.
Return to work plan
If you selected transitional duties, describe the return-to-work or stay-at-work plan by period. At discharge, record the final outcome: no time lost, returned to pre-injury work, returned to suitable work, or did not return with the reason, plus the discharge date.
Common reasons it’s delayed
- No claim number on every page.
- Weights entered without choosing pounds or kilograms.
- The pre-injury job demands column left blank, which leaves nothing to compare.
- Tolerances given without saying whether they were reported or observed.
- No final outcome or discharge date at discharge.
Submitting and who pays
Fax the completed, signed form to WCB Nova Scotia at 902-491-8001 with the claim number on every page. Only services WCB has pre-authorized are guaranteed payment. Invoice WCB by fax at the same number, with a separate invoice for each worker.