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1. Employee Information: Basic details of the employee including name, employee ID, position, and department
2. Medical Leave Details: Information about the period of medical leave, including start date and nature of medical condition (if disclosed)
3. Healthcare Provider Certification: Confirmation from the healthcare provider that the employee is fit to return to work
4. Return to Work Date: Specified date when the employee is cleared to return to work
5. Work Capacity Statement: Clear statement of the employee's ability to perform job duties (full capacity or with restrictions)
6. Required Accommodations: Specific workplace accommodations or modifications needed, if any
7. Duration of Restrictions: Timeframe for any temporary restrictions or accommodations
8. Follow-up Requirements: Any required follow-up medical appointments or assessments
9. Authorization: Signatures from healthcare provider, employee, and employer representative
1. Gradual Return to Work Plan: Detailed schedule for phased return to work, used when employee requires graduated reintegration
2. Specific Task Limitations: Detailed breakdown of restricted activities, used when complex job duties require specific guidance
3. Medication Effects Statement: Information about medication effects on work performance, used when prescribed medications may impact safety-sensitive positions
4. Workplace Safety Protocol: Special safety measures required, used in high-risk work environments
5. Remote Work Arrangements: Details of work-from-home accommodations, used when remote work is part of the accommodation plan
1. Schedule A - Physical Capacity Assessment: Detailed assessment of physical capabilities and limitations
2. Schedule B - Job Duties Checklist: Checklist indicating which specific job duties can be performed
3. Schedule C - Accommodation Plan: Detailed plan for implementing required workplace accommodations
4. Appendix 1 - Follow-up Schedule: Timeline for follow-up assessments and medical reviews
5. Appendix 2 - Emergency Response Plan: Procedures in case of medical emergency related to the condition
Healthcare Provider
Medical Condition
Modified Duties
Regular Duties
Return to Work Date
Essential Job Functions
Fitness for Work
Gradual Return to Work
Medical Leave
Physical Restrictions
Workplace Modifications
Undue Hardship
Work Capacity
Occupational Health and Safety
Personal Health Information
Temporary Restrictions
Permanent Restrictions
Medical Documentation
Work Schedule
Privacy and Confidentiality
Work Capacity Declaration
Accommodation Requirements
Duration and Review
Health and Safety
Compliance
Authorization and Consent
Modification of Duties
Follow-up Requirements
Dispute Resolution
Communication Protocol
Medical Information Handling
Reporting Requirements
Workplace Safety Measures
Healthcare
Manufacturing
Construction
Mining
Transportation
Retail
Education
Financial Services
Technology
Public Sector
Hospitality
Professional Services
Energy
Agriculture
Telecommunications
Human Resources
Occupational Health and Safety
Employee Relations
Benefits Administration
Risk Management
Legal
Labour Relations
Disability Management
Operations
Medical Services
Human Resources Manager
Occupational Health and Safety Coordinator
HR Business Partner
Benefits Administrator
Disability Management Specialist
Return to Work Coordinator
Employee Relations Manager
Health and Safety Manager
HR Director
Workers' Compensation Specialist
Department Manager
Supervisor
Union Representative
Risk Management Officer
Occupational Health Nurse
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