LETTER 1 – REQUEST FOR DOCTOR’S CERTIFICATE
This letter is used to request a Doctor’s Certificate Form (STO2 form) in
situations where you as manager/supervisor have determined that one is
required.
PLEASE NOTE
The language in this DRAFT letter is intended for use only as a model. Each
case is unique and specific language will be required in every instance.
Any italicized and bolded text or any text between these two symbols < >
needs to be removed or replaced appropriately for each case. Your own
ministry letterhead must be used. Your Early Intervention & Return to Work
Specialist is available to provide advice.
<Date>
<Employee’s name>
<Employee’s address>
Dear <Employee>:
Re: Doctor’s Certificate Form (STO2 form)
<delete references below that are not applicable>
<CEP Master Agreement, Appendix C, 1.04>
<PEA Master Agreement, Appendix A, 1.04>
<UPN/BCNU Master Agreement, Appendix 3, Section 1.04>
The Ministry is committed to the Early Intervention and Return to Work program
and I would like to work with you and your physician to explore how we might be
able assist you in an early return to work, in a modified capacity, if possible.
This may include options such as a gradual or full return to work trial with
modified or full duties. A trial period would provide you, your doctors and
Occupational Health Programs with an opportunity to ensure your recovery
continues while you readjust to your work tasks. Occupational Health Programs
supports us, as needed, by working with you and your doctors to review
treatment, rehabilitation and return to work opportunities.
In accordance with the collective agreement, have your doctor complete the
enclosed Doctor’s Certificate Form and return the supervisor’s portion to me by
<date>. The medical information provided on the form is will assist with returnto-work planning; identifying modified duties; and determining your entitlement for
payment of benefits under the Short Term Illness and Injury Plan (STIIP). Should
your absence continue for longer than 30 days, further forms may be required.
<OPTIONAL: in situations where the payment of STIIP benefits has already
been approved, but there is difficulty in obtaining medical documentation,
this letter can be modified to include a statement such as:
You continue to be absent from the workplace due to illness or injury, therefore
further medical information is required by <date> to determine entitlement for the
continued payment of benefits under STIIP and to support return-to-work
planning. Please note that failure to provide an STO2 as previously requested
may result in the suspension of benefits.>
I will contact you to discuss completion of your Time On Line entries <or Leave
Management Transaction Forms>. You will need to advise me whether you
wish to supplement STIIP or not.
As you may be aware, the Master Agreement states that an employee does not
earn vacation credits unless they receive at least 10 days pay at regular straighttime rates for each calendar month. Therefore, your vacation entitlement for the
year may be decreased accordingly while on STIIP.
<OPTIONAL: for part time employees, delete the above paragraph and
replace it with the following: As a part-time employee, any periods of sick
leave will result in adjustments to your vacation entitlement.>
<OPTIONAL: - for safety sensitive positions, e.g. positions in
environments where heavy equipment is used; positions required to carry
firearms; positions required to restrain or apprehend individuals:
The employer may require confirmation of a clearance to return to work through
specific testing or an Occupational Heath Programs examination for your
position.>
<Name>, if you have any questions, please feel free to call me at <phone #>.
Yours truly,
<Supervisor’s name>
<Title>
Enclosure(s)