Form 2967/Jan.

2019
Cardiovascular

Supplemental Medical Information (SMI)

Human Resources Department
Occupational Health and Employee Wellbeing

****
The TTC has adopted the principles outlined in the CMA policy: "Return to Work After an Illness or Injury". The
following form has been developed to facilitate and assist you in providing clinical evidence to help the TTC to develop
an early and safe return to work plan for our employee. We can offer modified work to suit a variety of functional and
cognitive abililties.
Last Name First Name Empl. No. Work Location Cost Centre

Address City/Town Province Postal Code Tel. No.

Job Title SBA LTD Claim No.

STDP WSIB 
TTC Disability Management Specialist
Name: Merlyn Rego Date:

Please Return Form By:

Part B - All Sections are Required to be Completed by Physician (date)

Primary Diagnosis: Additional Diagnosis:

Treatment
Surgical CABG Stent Angioplasty Date of Intervention:
Medication Start Date Dose Medication Start Date Dose
1. 4.
2. 5.
3. 6.
Cardiac Rehabilitation Program Yes No Duration: days;

AHA Cardiac Classification Was this classification confirmed by a stress test?

Class I Class II Class III Class IV Yes No When?

If cardiac testing has been performed to determine the following, please provide us with the results to assist in the RTW.
There are specific criteria by MTO that must be met prior to a commercial driver operating.
Stress Test - Most Recent METS Achieved: Date:
Echocardiogram - Most Recent Ejection Fraction % Date:

Based upon the AHA Cardiac Classification indicated above, please indicate the physical demands level at which the
patient is capable of functioning:
Typical
Physical Demands Occasional Frequent Constant Energy
Level 0 - 33% of workday 34 - 66% of workday 67 - 100% of workday Required
1.5 - 2.1
Sedentary 10 lbs Negligible Negligible
METS
10 lbs and/or walk/stand, 10 lbs and/or walk/stand, push/pull 2.2 - 3.5
Slight 20 lbs push/pull of arm and leg controls of arm and leg controls while seated METS

50 lbs 3.6 - 6.3

Medium 20 lbs 10 lbs
METS

Heavy 50 lbs 20 lbs 6.4 - 7.5

100 lbs
METS
Over 7.5
Very Heavy Over 100 lbs Over 50 lbs Over 20 lbs
METS
Form 2967/Jan. 2019
Employee Name Empl. No. Work Location Cost Centre

Has this condition been reported to the Ministry of Transportation as required by Reg. 203 of the Highway Traffic Act?
Yes No If Yes, Date Reported:
If No, please outline why you do not believe it is required:

Are there any psychological conditions (including occupational workplace stressors) that prevent a return to work?
Yes No (Provide details)

Additional questions or comments:

Return to Regular Work

Date:
Even though your patient may not be able to return to his or her own job, suitable modified work will be
provided. The information you provide will be used to develop a full return to work plan for your patient, up
to and including a return to regular duties.
Doctor's Name and Full Address

X
Doctor's Signature

Date Date Stamp

Please note: The TTC will reimburse $40.00 for this report if completed in full and legible.

Send completed form with invoice attached to: Toronto Transit Commission
Human Resources Department
Occupational Health and Employee Wellbeing
250 Bloor Street East, 11th Floor
Toronto, Ontario M4W 1E6
Fax. No. 416-397-8261

Personal Health Information as provided on this form is collected, used and disclosured to determine fitness for work
and such information is collected, used and disclosed under the authority of the Personal Health Information Act, 2004,
S.O. 2004, c. 3, as amended, and the City of Toronto Act, 1997 (No.2), S.O. 1997, c. 26, Part IV, as amended. Questions
about the collection, disclosure or use should be directed to the Occupational Health and Employee Wellbeing Section,
Human Resources Department, 250 Bloor Street East, 11th Floor, Toronto, Ontario M4W 1E6, 416-393-4572.