Part 1 - Employee, Please Complete:
I, ______________________, have been absent from work since _____________________.
(date)
I hereby consent to the completion of Part 2 by ______________________________.
(Print physician name)
__________________________
Signature of Employee
___________________________
Date
Part 2 - Physician, Please Complete:
1.
Employee is totally disabled: Yes 
a)
2.
No, employee is partially disabled 
Expected date of full recovery:
b)
Next appointment date:
Please outline his/her current limitations/restrictions and symptoms:
3.
General Nature of illness or injury:
□ Ortho – area: ___________________ □ Neurological
□ Cardiac □ Psychological
□ Other _________________________
4.
Is he/she receiving treatment? Yes 
a)
No 
If yes, what kind of treatment?
5.
Has or will a referral to a specialist been made? Yes  No Specialist Name:
6.
Please provide comments which you feel would be helpful:
________________________________
________________________
______________________________
Signature of Physician
Date
Address/Phone number
Please fax a customary fee for your service along with this completed report to the Near North District School Board
confidential line at 1-705-746-9562 by ___________________.
TO WHOM IT MAY CONCERN: (Attending Health Professional)
The Near North District School Board supports early vocational
rehabilitation/accommodations and has a Disability Management Program that will
be implemented at the earliest stage possible.
Upon receipt of the completed Medical information (reverse side), the recommended
restrictions and limitations are reviewed and compared with available existing physical
demands analysis. Confidentiality of Health related information will be maintained to the
highest degree possible.
If necessary, temporary modified placement is provided for our employees,
establishing the goal of early vocational rehabilitation. Accommodations may be
met through modifications to their regular positions or by placement in other
positions more suited to their current restrictions and limitations.
Accommodations are monitored closely to ensure the restrictions and limitations are being
adhered to and that we receive ongoing medical reports regarding any changes.
I thank you for your support and care of our valued employee. If you have any questions or
concerns, please feel free to call the undersigned.
Sincerely,
Paulette LaBrash, C.R.T.W.C.
Human Resources Administrator-Rehabilitation
Near North District School Board
Phone: 705-746-9371, Ext. 7007
Secure Fax: 705-746-9562