HomeMy WebLinkAboutOCDSB 972 OSSTF SICK LEAVE PACKAGEOSSTF ABILITIES FORM (2 pages)
Ottawa-Carleton District School Board
133 Greenbank Road, Ottawa, K2H 6L3
FAX COMPLETED FORM TO: 613-596-8798 or 613-596-8726
Employee Group: Requested By:
WSIB Claim: Yes No WSIB Claim Number:
To the Employee: The purpose for this form is to provide the Board with information to assess whether you are able to perform the essential
duties of your position, and understand your restrictions and/or limitations to assess workplace accommodation if necessary.
Employee’s Consent: I authorize the Health Professional involved with my treatment to provide to my employer this form when complete. This
form contains information about any medical limitations/restrictions affecting my ability to return to work or perform my assigned duties.
1.Health Care Professional: The following information should be completed by the Health Care Professional
Please check one:
Patient is capable of returning to work with no restrictions.
Patient is capable of returning to work with restrictions. Complete section 2 (A & B) & 3
I have reviewed sections 2 (A & B) and have determined that the Patient is totally disabled and is unable to return to work a t this time.
Complete sections 3 and 4. Should the absence continue, updated medical information will next be requested after the date of the follow up
appointment indicated in section 4.
First Day of Absence:
__________________________
General Nature of Illness (please do not include diagnosis):
_____________________________________________________
Date of Assessment:
dd mm yyyy
2A: Health Care Professional to complete. Please outline your patient’s abilities and/or restrictions based on your objecti ve
medical findings.
PHYSICAL (if applicable)
Walking:
Full Abilities
Up to 100 metres
100 - 200 metres
Other (please specify):
Standing:
Full Abilities
Up to 15 minutes
15 - 30 minutes
Other (please specify):
Sitting:
Full Abilities
Up to 30 minutes
30 minutes - 1 hour
Other (please specify):
Lifting from floor to waist:
Full Abilities
Up to 5 kilograms
5 - 10 kilograms
Other (please specify):
Lifting from Waist to
Shoulder:
Full abilities
Up to 5 kilograms
5 - 10 kilograms
Other (please specify):
Stair Climbing:
Full abilities
Up to 5 steps
6 - 12 steps
Other (please specify):
Use of hand(s):
Left Hand Right Hand
Gripping Gripping
Pinching Pinching
Other (please specify): Other (please specify):
Bending/twisting
repetitive movement of
(please specify):
Work at or above
shoulder activity:
Chemical exposure to: Travel to Work:
Ability to use public transit
______________________
Ability to drive car
Yes No
______________
Yes No
Employee Name:
(Please print)
Employee Signature:
Employee ID: Telephone No:
Employee
Address:
Work Location:
OSSTF ABILITIES FORM (2 pages)
Ottawa-Carleton District School Board
133 Greenbank Road, Ottawa, K2H 6L3
FAX COMPLETED FORM TO: 613-596-8798 or 613-596-8726
2B: COGNITIVE (please complete all that is applicable)
Attention and Concentration:
Full Abilities
Limited Abilities
Comments:
Following Directions:
Full Abilities
Limited Abilities
Comments:
Decision- Making/Supervision:
Full Abilities
Limited Abilities
Comments:
Multi-Tasking:
Full Abilities
Limited Abilities
Comments:
Ability to Organize:
Full Abilities
Limited Abilities
Comments:
Memory:
Full Abilities
Limited Abilities
Comments:
Social Interaction:
Full Abilities
Limited Abilities
Comments:
Communication:
Full Abilities
Limited Abilities
Comments:
Please identify the assessment tool(s) used to determine the above abilities (Examples: Lifting tests, grip strength tests, Anxiety
Inventories, Self-Reporting, etc.
Additional comments on Limitations (not able to do) and/or Restrictions (should/must not do) for all medical conditions:
3: Health Care Professional to complete.
From the date of this assessment, the above will apply for approximately:
6-10 days 11- 15 days 16- 25 days 26 + days
Have you discussed return to work with your patient?
Yes No
Recommendations for work hours and start date (if applicable):
Regular full time hours Modified hours Graduated hours
Start Date: dd mm yyyy
Is patient on an active treatment plan?: Yes No
Has a referral to another Health Care Professional been made?
Yes (optional - please specify): ________________________________________________ No
If a referral has been made, will you continue to be the patient’s primary Health Care Provider? Yes No
4: Recommended date of next appointment to review Abilities and/or Restrictions: dd mm yyyy
Completing Health Care Professional Name:
(Please Print)
Date:
Telephone Number:
Fax Number:
Signature:
OSSTF – Central Agreement - 2015
Dear Health Care Professional:
The Ottawa-Carleton District School Board (OCDSB) is committed to assisting employees in their
recovery and providing safe return to work. The OCDSB will provide transitional modified duties
and/or modified hours of work, if required.
Employees must provide sufficient objective medical documentation to support their absence, to
qualify for benefits, and to assist in the development of a return to work plan appropriate to the
employee’s abilities and limitations.
Attached is the OCDSB Abilities Form. If your patient is ready to return to work with
restrictions please ensure to complete section 2 (A&B). Please return the form to the Wellness
Team via email at: employee.wellness@ocdsb.ca or by fax at 613-596-8798 or 613-596-8726.
A Disability Management Coordinator from the OCDSB will work with your patient to support and
help your patient during his/her recovery and return to work.
Confidentiality of medical information will be respected at all times. The employee’s functional
capabilities and / or restrictions will be shared with appropriate staff within the OCDSB.
We thank you in advance for your assistance and invite you to contact us at 613-596-8250 with
any questions.
Sincerely,
Employee Wellness
Employee Wellness & Disability Management
613-596-8250
Attached: OSSTF Abilities Form
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