The Statement Of Fitness For Work Form is a critical document used in Canadian workplaces when employees need to validate their health status and work capabilities following an illness, injury, or medical condition. This form serves multiple purposes: it provides medical evidence for absence management, supports return-to-work planning, and helps employers implement appropriate workplace accommodations. The document must comply with federal and provincial privacy laws, including PIPEDA, as well as relevant employment standards and human rights legislation. It is typically required when an employee has been absent due to health issues, is returning to work after medical leave, or needs workplace modifications due to health conditions. The form includes essential medical assessments, recommended workplace adjustments, and duration of modifications while protecting sensitive medical information.
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1. Employee Information: Basic identifying details including name, date of birth, employee ID, and contact information
2. Employer Information: Company name, department/division, supervisor name, and workplace location
3. Medical Assessment: Healthcare provider's evaluation of the employee's fitness for work status
4. Work Capacity Declaration: Clear statement whether the employee is 'Fit for Work', 'Not Fit for Work', or 'May be Fit for Work with Modifications'
5. Duration: Specific period for which the assessment applies, including start and end dates
6. Healthcare Provider Details: Name, qualification, registration number, and contact information of the assessing healthcare provider
1. Workplace Modifications: Required when 'May be Fit for Work with Modifications' is selected - details specific workplace adjustments needed
2. Gradual Return to Work Plan: Used when a phased return to work is recommended - outlines stages and timeline for return
3. Follow-up Requirements: Include when ongoing medical review is needed - specifies next assessment date and requirements
4. Specific Work Restrictions: Used when certain tasks or conditions must be avoided - details specific limitations
5. Injury/Illness Information: Optional section for workplace injuries or illnesses that require Workers' Compensation Board reporting
1. Physical Demands Assessment Form: Detailed checklist of physical requirements of the job and employee's current capabilities
2. Job Description: Current job description and essential duties to assist healthcare provider in assessment
3. Workplace Accommodation Options: List of available workplace modifications and alternative duties
4. Privacy Consent Form: Authorization for collection and disclosure of medical information
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