Medical Form 8-10

Indicate if this is an initial visit (First Medical Report of Accident or Occupational Disease) or a progress report (Medical Progress Report).

Provide patient's Medicare number and WorkSafeNB claim number, if known. State patient's address and date of birth. Indicate employer, occupation and date of incident or first report of occupational illness.

Indicate injury type and body part affected. Provide description and subjective and objective findings. In addition, please attach any applicable clinic notes or charts. Indicate best working diagnosis, diagnostics ordered and treatment plan.

This section is critical for helping the employer and worker develop and follow an early and safe return-to-work plan. WorkSafeNB and the New Brunswick Medical Society endorse Choosing Wisely Canada recommendations on occupational medicine. These include:

Don’t endorse clinically unnecessary absence from work.

There is substantial evidence to support the positive link between work and health (physical, mental and social health). Both employment and income are separate determinants of health and are used as health status indicators. Absence from work contributes to declining health, slower recovery times, and longer duration of disability.
Maintaining and restoring working capacity is an important function of health services which improves function and can also impact upon recovery and prognosis. Supporting unnecessary restrictions or total disability (absence from work) creates disability which in turn negatively impacts upon health. When asked to provide an opinion on functional abilities to employers or insurers, the focus should be on abilities; restrictions should be objective, specific, and listed only when absolutely medically indicated.

Don’t prescribe opiates for the treatment of acute or chronic non-cancer pain without first assessing side effects, work status and capacity to drive a motor vehicle.

Increases in opioid prescribing have been accompanied by simultaneous increases in abuse, serious injuries, and deaths from overdose. Compared to those on no or lower opiate doses, those prescribed higher opiate doses have increased disability risk and duration. The use of opiates can result in effects such as euphoria, drowsiness or inability to concentrate.
Cognitive and psychomotor ability are essential functions for driving a motor vehicle and other complex work tasks. Those who prescribe opiates may be obligated to report a patient’s inability to drive safely.

See more Choosing Wisely recommendations.

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Physician functional abilities recommendation:

Choose one of two options:

1. Medically able to perform usual work duties.

2. Medically able/unable to perform duties as detailed below. WorkSafeNB may arrange a formal assessment of functional abilities.

Choose 1 if the worker can safely return to usual work duties with no changes to workplace environment or hours.

Choose 2 if the patient can safely participate in any workplace accommodation. Accommodation may include reduction of hours (gradual return), ergonomic modifications (sitting vs. standing for example), use of tools or aids, or change in workplace duties, such as alternative work or transitional work. Provide a brief functional assessment, indicating your patient’s work capabilities. Employers have a duty to accommodate reasonable restrictions and limitations. Even working one hour per week will help the worker's recovery. WorkSafeNB may provide ongoing functional assessments.

If you've selected option 2, indicate "able" or "unable" for each of the 12 functions listed.

If you're unsure of your patient's job demands or how the injury or illness may affect your patient's job, please speak with your patient's employer or the WorkSafeNB case manager. A work-related functional evaluation or job task analysis may help you match your patient's functional capabilities with safe and appropriate work

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Other limitations: Please indicate any medical restrictions, such as total number of hours a patient can work per day or week, or prohibiting factors on abilities.

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Number of days valid: Please indicate how many days the assessment covers. Note: The maximum is 14 days.

Indicate your provider type, WorkSafeNB payee number, provider office service code as well as office address and phone number. Please print your name and sign the completed form.

Once completed and signed, provide the second page of Medical Form 8-10 to the patient. This section helps the employer and patient develop and follow a return-to-work plan. 

Submit the first page of Medical Form 8-10 to WorkSafeNB in one of four ways:

• MyServices: Please register for MyServices to access secure email.
• Fax (toll-free): 1 888 629-4722 (If a report is faxed, please do not mail it as well.)
• In person: You may deliver the form to one of our five locations.
• Mail: WorkSafeNB, 1 Portland St., P.O. Box 160, Saint John, N.B. E2L 3X9 

Call our physician phone line, 1 877 647-0777, to ask about early and safe return-to-work programming, modified duties, a particular WorkSafeNB claim, invoice or employer coverage. We are here to help.