SICK LEAVE/RETURN TO WORK FORM
Note: Any costs associated with providing this information is the responsibility of the employee.
Section A- EMPLOYEE DETAILS: Employee to Complete
Employee Name:
Date of Birth:
/
/
Contact Phone:
dd / mm /yyyy
Department:
Supervisor:
Job Title:
I authorize my physician to release this completed form to the Disability Management Team (for Staff) or Occupational Health Team (for
Faculty) at the University of Waterloo.
Employee Signature:
Date:
/
/
dd / mm /yyyy
Section B- SICK LEAVE DETAILS: Physician to Complete
First date of Absence:
/
/
Has your patient been absent from work for a related complaint in the past 2 months?
☐ yes
☐ no
dd / mm /yyyy
Please check one:
☐ Patient capable of returning to work with no limitations
☐ Patient is physically unable to return to work at this time
☐ Patient is capable of returning to work with restrictions (complete Section C-Workplace Functional Capacity)
NB: If a modified return to work plan is required it is expected that a return to full pre-disability hours and duties will normally occur over a maximum of 6 to 8
weeks.
Have you discussed return to work with your patient?
☐ yes
☐ no
Date cleared for return to work
:
/
/
dd / mm /yyyy
To modified duties/hours:
/
/
To full hours/duties:
/
/
dd / mm /yyyy
dd / mm /yyyy
If return to work is unknown at this time please provide prognosis:
☐
☐
Follow-up appointment:
Date of next apt.:
/ /
None required
As needed
dd / mm /yyyy
Name of Physician:
Telephone Number:
Physician Signature
Date:
/
/
:
dd / mm /yyyy
Section C- WORKPLACE FUNCTIONAL CAPACITY:
This section should only be completed by the Physician when accommodation is requested.
Functional Abilities and/or Limitations: If your patient is able to remain or return to work but has any limitations, please provide the Nature of Condition and
complete the applicable sections below. DO NOT include any technical or medical details such as diagnosis or symptoms. Provide a plain language general
statement of the person’s illness or injury.
Nature of Condition:
Walking:
Standing:
Sitting:
Lifting from floor
Lifting from waist to
Stair climbing:
Ladder climbing:
☐ Full abilities
☐ Full abilities
☐ Full abilities
☐ Full abilities
☐ Full abilities
to waist:
shoulder:
☐ Full abilities
☐ Full abilities
☐ Up to 100 metres
☐ Up to 15 minutes
☐ Up to 30 minutes
☐ Up to 5 steps
☐ 1-3 steps
☐ Up to 5 kgs
☐ Up to 5 kgs
☐ 100-200 metres
☐ 15-30 minutes
☐ 30 minutes-1 hour
☐ 5-10 steps
☐ 4-6 steps
☐ 5-10 kgs
☐ 5-10 kgs
☐ Other
☐ Other
☐ Other
☐ Other
☐ Other
☐ Other
☐ Other
☐ Bending,
☐ Work at
☐ Limited use of
Limited
☐ Potential side
Cognitive/Psychological:
pushing/pulling
☐ Difficulties performing simple and repetitive tasks
twisting
or above
hand (s):
effects from
with:
repetitive
shoulder
Left
Right
medications (please
☐ Problems maintaining focus/concentration on the job
☐ Left arm
☐
☐
movement of
activity
Gripping
specify) Do not
☐ Limited ability to perform complex and varied tasks
☐ Right arm
(please specify)
☐
☐
include names of
Pinching
☐ Reduced energy and pace required for the job
☐ Other
medications
☐
☐
☐ Difficulty maintaining healthy co-worker relationships
Other
Additional Comments on limitations:
From the date of this assessment, the above will apply for approximately:
☐ 1-2 days ☐ 3-7 days ☐ 8-14 days ☐ 14+ days
Physician’s Signature: __________________________________
Date: _____________________________________
The University of Waterloo gathers and maintains information used on this form for the purposes of supporting the University’s income continuance programs. Information will be protected, used, and released in compliance with applicable law, including but not
limited to Ontario’s Personal Health Information Protection Act (S.O.2004, c.3), Workplace Safety and Insurance Act (S.O. 1997, c.16) and Occupational Health and Safety Act (R.S.O. 1991, c.0.1) and uWaterloo Policies. Questions about the collection, use and
HRDIS-FR-002 Rev. 0 22-April-2015
disclosure of information on this form should be directed to the Disability Advisor, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, Canada N2L 3G1