Return To Work Doctor Evaluation Form Template for Canada

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Key Requirements PROMPT example:

Return To Work Doctor Evaluation Form

"I need a Return to Work Doctor Evaluation Form for our manufacturing facility in Ontario, specifically designed for employees returning from physical injuries, with extra emphasis on safety-sensitive positions and detailed physical capacity assessments."

Document background
The Return To Work Doctor Evaluation Form is a crucial document in Canadian workplace health and safety management, designed to facilitate safe and effective returns to work following employee absences due to illness, injury, or other medical conditions. This form is required when an employee needs medical clearance to resume work duties, whether returning to full capacity or requiring modified duties. It ensures compliance with Canadian federal and provincial legislation, including privacy laws (PIPEDA), human rights requirements, and occupational health and safety regulations. The document bridges communication between healthcare providers and employers while protecting sensitive medical information, only disclosing functional abilities and workplace requirements. It's particularly important for documenting necessary workplace accommodations and establishing clear return-to-work parameters.
Suggested Sections

1. Patient/Employee Information: Basic identifying information including name, date of birth, employee ID, and contact information

2. Employer Information: Company name, division/department, supervisor contact information

3. Absence Information: First day of absence, nature of condition (work-related/non-work-related), date of injury/illness onset

4. Medical Assessment: Current diagnosis, prognosis, and treatment plan (noting only functional information, not detailed medical history)

5. Functional Capabilities: Detailed assessment of patient's current physical and cognitive capabilities relevant to job duties

6. Work Restrictions and Accommodations: Specific limitations and required workplace modifications

7. Return to Work Recommendation: Clear statement of whether employee can return to work and in what capacity (full duties, modified duties, or unable to return)

8. Duration and Follow-up: Expected duration of restrictions, date of next assessment, and follow-up plan

9. Healthcare Provider Attestation: Treating physician's information, signature, date, and professional license number

Optional Sections

1. Mental Health Assessment: Additional section for cases involving mental health conditions or stress-related returns

2. Specific Job Task Analysis: Detailed analysis of employee's ability to perform specific job tasks, used when job involves specialized physical requirements

3. Medication Effects: Assessment of any medication's impact on work performance and safety, particularly relevant for safety-sensitive positions

4. Gradual Return to Work Schedule: Detailed timeline for progressive return to full duties, used when a graduated return is recommended

5. Risk Assessment: Evaluation of potential risks to employee or others, particularly important in safety-sensitive positions

Suggested Schedules

1. Physical Demands Assessment Form: Detailed checklist of physical requirements for the employee's specific job role

2. Functional Abilities Measurement Scale: Standardized scale for measuring various physical and cognitive capabilities

3. Workplace Accommodation Checklist: List of possible workplace modifications and their implementation status

4. Follow-up Schedule Template: Timeline for subsequent medical evaluations and progress assessments

5. Privacy Notice and Consent Form: Document outlining how medical information will be used and shared, requiring employee signature

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Relevant legal definitions
Relevant Industries

Manufacturing

Construction

Healthcare

Mining

Transportation

Retail

Warehousing

Public Service

Education

Energy

Forestry

Agriculture

Hospitality

Industrial Services

Professional Services

Relevant Teams

Human Resources

Occupational Health and Safety

Risk Management

Employee Relations

Operations

Disability Management

Workers' Compensation

Medical Services

Labor Relations

Relevant Roles

Human Resources Manager

Occupational Health Nurse

Health and Safety Coordinator

Return to Work Specialist

HR Business Partner

Disability Management Coordinator

Employee Relations Manager

Occupational Health and Safety Manager

Workers' Compensation Administrator

Risk Management Specialist

HR Director

Department Supervisor

Plant Manager

Operations Manager

Industries
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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