Form 1: Assessment of Attendant Care Needs

Effective October 1, 2016.

This form is used to report the future needs for the attendant care required by you as a result of your motor vehicle accident. This form must be completed by an occupational therapist or a registered nurse (in this form referred to as the Assessor).

This form has five parts, which are as follows:

1. Part 1: Level 1 Attendant Care;
2. Part 2: Level 2 Attendant Care;
3. Part 3: Level 3 Attendant Care;
4. Part 4: Calculation of Attendant Care Costs; and
5. Part 5: Signature of Assessor(s).

Either the occupational therapist or the registered nurse must complete all of the relevant parts of this Form 1. The occupational therapist or the registered nurse shall make copies and give one to:

1. You, the applicant;
2. Your legal representative; and
3. Your health practitioner (usually your family doctor).

All fields of this Form 1 must be completed subject to the following exceptions:

• *required if known;
• **at least one field in this section; and
• ***optional.

Please note, you should also review with your legal representative the other accident benefits available to you under the Statutory Accident Benefits Schedule (SABS) for possible reimbursement of other losses and expenses (such as, but not limited to, housekeeping and home maintenance, transportation, home modifications and other medical and rehabilitation expenses).