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Statement Of Fitness For Work Form Template for Canada

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Key Requirements PROMPT example:

Statement Of Fitness For Work Form

"I need a Statement of Fitness for Work Form for an employee returning to work after surgery, with a gradual return-to-work plan starting March 15, 2025, including specific physical restrictions and reduced hours for the first month."

Document background
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.
Suggested Sections

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

Optional Sections

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

Suggested Schedules

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

Authors

Alex Denne

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

Relevant legal definitions





























Clauses


















Relevant Industries

Healthcare

Manufacturing

Construction

Retail

Education

Financial Services

Technology

Mining

Transportation

Public Sector

Hospitality

Professional Services

Energy

Telecommunications

Relevant Teams

Human Resources

Occupational Health and Safety

People Operations

Employee Relations

Benefits Administration

Risk Management

Health Services

Operations Management

Labor Relations

Relevant Roles

Human Resources Manager

Occupational Health and Safety Manager

Return to Work Coordinator

Disability Management Specialist

HR Business Partner

Health and Safety Officer

Employee Relations Manager

Benefits Administrator

HR Director

Workplace Accommodation Specialist

Line Manager

Department Supervisor

Medical Leave Administrator

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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