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<br />February 2012 revision (ETFO, PVP, Union Exempt) <br />OTTAWA-CARLETON DISTRICT SCHOOL BOARD <br />Standardized Medical Certificate <br />Phone: 613-596-8250 Fax: 613-596-8798 <br />Part A -To Be Completed by Employee <br /> <br />Last Name: __________________________________First Name: _______________________ <br />Work location: __________________________________EIN: _________________________ <br />I will be / have been absent from work since (date) ____________. I hereby consent to the completion and submission of the <br />appropriate sections of this form by my regulated health care professional for submission in confidence to the Employee Wellness & <br />Disability Management Division at Ottawa-Carleton District School Board. <br />______________________________________________ _______________________________________ <br /> Date <br />Part B - <br />1. This employee sought medical attention for this illness on _________________________ (date) <br />2.This Employee is Fit to return to regular duties Date of return to work _________________________ <br />3. This employee is TOTALLY DISABLED <br />Have you discussed the possibility of a modified return to work plan with the employee? Yes No <br /> <br />Expected date of recovery: _________________Expected date of return to regular work: __________________ or Modified duties: ________________ <br />Next appointment date: _______________________________ <br />4. Is this employee receiving ongoing treatment? : Yes No <br />If yes, please complete the following: <br /> i) Duration of treatment plan: ________________________________________________ <br /> ii) Restrictions and/or limitations (COMPLETE SECTION C WHERE APPLICABLE ONLY) <br /> iii) Expected duration of restrictions and/or limitations: _____________________________ <br />5.This employee is fit to return to work or remain at work with accommodations <br /> COMPLETE SECTION C ON PAGE 2 WHERE APPLICABLE <br />Expected duration of accommodation requirement: _____________________ Next appointment date: ___________________________ <br />6. Comments and signature section: <br />Provide additional comments and/or information that should be considered in order to assist in a safe and healthy return to work for your patient. <br />_________________________________________________________________________________ <br />_________________________________________________________________________________ <br /> <br />Date : (MM/DD/YY) <br /> <br />Telephone: <br /> <br />Please complete and return this form to the Employee Wellness & Disability Management Officer, Employee Wellness & Disability <br />Management Division at the Ottawa-Carleton District School Board within 3 days. Confidential Fax number is 613-596-8798. Thank <br />You. <br />Freedom of Information Disclaimer: <br />Authority: The above information is collected under the authority of the Education Act (Ch.E2), Ottawa-Carleton District School Bo <br />Workplace Safety and Insurance Board (WSIB). <br /> <br />Users: <br />Users of this information will be limited to the Employee Wellness & Disability Management Division of the Human Resources Department. The information will be used to assist the employee <br /> with a <br />successful re-entry program and rehabilitation back into the workplace. <br /> <br />PAGE 2 PART C - <br />Page 1 of 2 <br /> <br />