Mackenzie Health Attending Physician's Statement Instructions: Employees complete Section A and the Physician completes Section B and D and possibly C, depending on the circumstance. Employees are responsible for ensuring the form is completed by their Physician and forwarded to the Occupational Health Unit. PART A - Employee Information & Consent Tobe canpitied by enpoyee empinyoos Nane: Genre, Obtara-ume- UniDopartment: “Hb flwr- Nefhro ~76! Managers Name: sobTite:_Clinteat Exten Home Phone: 489-7744250 First Day Absance:_-28th Apel 2003 By complating and signing this form, | hereby authorize my health care practioner to release limitationsfrestrctions andlor functional information pertaining to my current absence to Mackenzie Health's Occupational Health Unit. This information is for the purpose of determining my fitness to work andlor the need for any required accommodation and/or to substantiate my absence due to iliness and/or. eligibility for benefits In addition, | authorize Mackenzie Health's Occupational Health UnivPhysician to contact my health care practioner for the development and implementation of my Early and Safe Retum to Work Plan, if required. This authorization is effective (a) as a single authorization or (b) for the duration of my current disability (circle choice). (understand that | may revoke this authorization at any time either in a written decurnent signed by me, or electronically, provided that such electronic revocation is sufficient authentication to establish my identity, Employee's Signature: Sibir Date RBbb oe, DoD All medical information received will be kept in strict confidence in the employee's health file.Part B - Iliness/Injury Information {0 be completed by Treating Physician) Mackenzie Health is committed to offering modified or graduated “RTW" programs designed to ensure a safe and early return to work of employees who are recovering from injury or iliness. ‘Type of Disability: lor-occupationalinjunylness C1 Occupational injuyfness (WSIB) © Optional Medical Procedure (not covered by CHIP) _@ MVA Gonoral nature of Iiinessfinjury (a genoral statement of a person's illness or injury): B-oM cute Ly eghob leet Loateunre 's the currenttinss a communicable disease? a Yes No if yes, has the communicable disease been reported to Public Health as required by law? o Yes c No Date of first appointment: _ 202.3 - mA ~ ©) __ Date of most recent appointment:_2023 -MAY~—o T Date of next scheduled appointment: Av. & Ow Is the employes being roferred to a Treating Specialist? Yes No 1s, or was the employee hospitalized for this injuryliiness? KYes c No From: safe 2973 To: cuytunrt— In my opinion, supported by objective medical evidence, the employee is/has been: yFotally Disabled Not Totally Disabled from performing his/her reqular duties Date total disebilty commenced: 2023 - mayo | Anticipated date of return to work: Ua lino + Prognosis for return to regular duties: 0 Good Poor Yreortain Teonfirm the employee is under my active and continuous Care and is following the treatment I have prescribed: Yves No Please describe the treatment plan in general terms: DEG Chenethoropy i employee is nat returning to work, or doos not require any modified duties or accommodation, please proceed to Part D. DO NOT COMPLETE PART C.ae Part = Abilities, Restrictions and Limitations: to be completed only fthe employee (Yast is returning to work with restrictions. (To be completed by Treating Physician) Physical Capabilities: = Sedentary Duties: = Sitting + _No requirement to it, carry, pushipull or climb + Walking from one task area to another + No climbing + Limited carrying - no greater than 5 kgs. + Limited tfting, pushing or pulling - no greater than 10 kgs, 0 Medium Duties: + Standing, walking, sitting as required + Limited liting, carrying, pushing or puling no greater than 15 kg + Umited climbing Cognitive Capabilities: if applicable, please indicate limitations in cognitive function: Coherent fies one Judgment Ilicood o Adequate o Poor Concentration © Good 5 Adequate ffPoor This individual can work ‘© Independently © With supervision o With Assistance Other restrictions (etease inieat): Recommended RTW: 1 regular hours a graduated (details): Estimated duration of restrictions/graduated plan: Part D: Physician Information ware: Stun Clhoun, tot College gare, Room B-3S¥ Torah on mse CF , C Ss aa Tan 1, tor3 Phone: (#3) 4bs- shy & Office Stamp: Fox (ab 446 ~ 4568 ‘Thank you for your assistance, This form can $e faxed back to the confidential fax of ONS at 905-883-2149 or ‘emaited to Occupations HealtnUn@Mackonzietleat.ca if you have a socure One Mail email account,