In Ontario, the Functional Abilities Form (Form 2647A) is completed by your treating healthcare provider, not by you. You or your employer request it, bring or send it to your doctor, physiotherapist, or other licensed provider, and they fill in the checkboxes describing what you can physically do right now. The completed form then goes to you, your employer, and the WSIB so everyone can plan a safe return to work.1Workplace Safety and Insurance Board. Functional Abilities Form
What the Form Is For
The FAF is a one-page assessment that describes your current physical abilities and restrictions, not your diagnosis or medications. It shifts the return-to-work conversation from what you cannot do to what you can do, so your employer can match you with suitable duties.1Workplace Safety and Insurance Board. Functional Abilities Form The form focuses on physical function; it wasn’t designed with dedicated fields for cognitive or psychological limitations, though your provider can note those in the comments section.2Workplace Safety and Insurance Board. Functional Abilities Form for Planning Early and Safe Return to Work
Who Requests It and Who Fills It Out
Either you or your employer can request the form. The medical portion is completed by the health professional actively treating you, which can be a doctor, physiotherapist, or another licensed healthcare provider. You do not complete the medical sections yourself.1Workplace Safety and Insurance Board. Functional Abilities Form
You or your employer can fill in the administrative details at the top before the appointment. Section A asks for the worker’s name, address, phone number, and date of birth, and the employer’s name, phone, and fax. It doesn’t ask for a social insurance number.2Workplace Safety and Insurance Board. Functional Abilities Form for Planning Early and Safe Return to Work
Where to Get a Blank Copy
You can download Form 2647A directly from the WSIB website.3Workplace Safety and Insurance Board. Functional Abilities Form for Early and Safe Return to Work (2647A) Many clinics also keep copies on hand. If you already have a WSIB claim number, bring it to the appointment so the form links to the right file.
What Your Provider Will Assess
The provider works through a series of checkboxes rating your current capacity in each area. Categories include walking distance, standing and sitting tolerance, lifting from floor to waist and waist to shoulder, stair and ladder climbing, and travel by transit or driving. The form also covers gripping and pinching, work at or above shoulder level, bending, twisting, repetitive movements, pushing and pulling, operating motorized equipment such as forklifts, exposure to heat, cold, noise, scents, or vibration, and any side effects from medication (noted without listing specific drugs). Anything that doesn’t fit a checkbox goes in the “Additional Comments” field in Section E.2Workplace Safety and Insurance Board. Functional Abilities Form for Planning Early and Safe Return to Work
Before the appointment, review your job description with your provider. Knowing the physical demands of your regular role helps them give a more accurate reading of whether you can return to that position, need temporary modified duties, or neither.
How the Completed Form Gets Submitted
Once your provider finishes the assessment, copies need to reach three parties: you, your employer, and the WSIB. The provider confirms on the form itself which parties received a copy.1Workplace Safety and Insurance Board. Functional Abilities Form
To send pages 2 and 3 to the WSIB, the options printed on the form are:
- Fax to 416-344-4684 or toll-free 1-888-313-7373
- Mail to Workplace Safety and Insurance Board, 200 Front Street West, Toronto, ON M5V 3J1
- Electronic submission for providers registered with the WSIB’s eProvider Reporting Service4Workplace Safety and Insurance Board. Online Services for Providers
Keep your own copy. If a dispute later arises about your restrictions or the date of assessment, that copy is your proof.
Who Pays the Provider
You don’t pay for the form. The WSIB pays the healthcare provider directly. The fee is $45.00 per FAF submission.5Workplace Safety and Insurance Board. Fee Schedule: Physician A 2.0 percent increase to existing fee-for-service rates across 11 regulated health professions in Ontario took effect January 1, 2026, so providers should confirm the current rate on the WSIB fee schedule before billing.6Workplace Safety and Insurance Board. Health Care Provider Fees Billing goes through the TELUS Health Provider Portal.
If You Disagree With What the Form Says
Start by contacting the WSIB decision maker on your file and explaining your concerns. Provide any new medical evidence you have. If the decision doesn’t change, you can file a formal objection.
To object, submit an Intent to Object form or a written letter that includes your name, claim number, the date of the decision you are contesting, and the specific issues in dispute. Get the Intent to Object form from the WSIB website, by mail, or by calling 1-800-387-0750. Submissions go through wsib.ca/submit or by mail.7Workplace Safety and Insurance Board. Appeals Practices and Procedures
Deadlines are short. Return-to-work decisions carry a 30-day objection deadline; most other WSIB decisions allow six months.8Workplace Safety and Insurance Board. Employer Instruction Sheet: Intent to Object Form The exact deadline appears on the decision letter, so read it closely. After you file, the WSIB’s Access Department sends you an Appeal Readiness Form, and your appeal doesn’t move to the Appeals Services Division until you return it.7Workplace Safety and Insurance Board. Appeals Practices and Procedures
What Happens If You Don’t Cooperate
Stalling has a cost. If the WSIB determines that a worker is not cooperating with return-to-work efforts, it sends a written notice. Ten days after that notice, wage loss benefits drop by 50 percent for 14 days. If cooperation still hasn’t resumed, the WSIB either suspends benefits entirely or reduces them to reflect the earnings the worker could have been making.9Workplace Safety and Insurance Board. RTW Co-operation Obligations
Employers face parallel consequences. A non-cooperating employer can be assessed a penalty equal to the cost of the worker’s benefits.9Workplace Safety and Insurance Board. RTW Co-operation Obligations In either case, penalties end once the WSIB sees evidence that cooperation has resumed, so re-engaging with the process is the quickest way out.