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Physicians complete Section B (Sick Leave Details) and complete Section C only when accommodation is requested.",{"name":70,"@type":61,"acceptedAnswer":71},"What information should be avoided when completing Section C?",{"text":72,"@type":64},"Section C should not include technical or medical details such as diagnosis or symptoms; it requires plain-language statements of illness or injury and work-related functional limitations.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},277633,1790227489,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},5909892115043,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","*  \nSection A-EMPLOYEE DETAILS: Employee to Complete  \ndd / mm /yyyy  \nEmployee Name:   Date of Birth:  / /  Contact Phone:    \nDepartment:   Supervisor:   Job Title:   \nI authorize my physician to release this completed form to the Disability Management Team (for Staff) or Occupational Health Team (for Faculty) at the University of Waterloo.  \nEmployee Signature: ~~ ~~ Date: ~~ ~~dd~~ ~~/~~/~~mm~~ ~~/yy~~ ~~  \nSection B-SICK LEAVE DETAILS: Physician to Complete  \nFirst date of Absence:~~ ~~dd~~ ~~/~~/~~mm~~ ~~/yy~~ ~~ Has your patient been absent from work for a related complaint in the past 2 months? ☐ yes ☐ no  \nPlease check one: ☐ Patient capable of returning to work with no limitations ☐ Patient is physically unable to return to work at this time  \n☐ Patient is capable of returning to work with restrictions (complete Section C-Workplace Functional Capacity)  \nNB: Ifa modified return to work plan is required it is expected that a return to full pre-disability hours and duties will normally occur over a maximum of 6 to 8 weeks.  \nHave you discussed return to work with your patient? ☐ yes ☐ no Date cleared for return to work:  / /   \ndd / mm /yyyy  \nTo modified duties/hours:  / /  To full hours/duties: / /   \ndd / mm /yyyy dd / mm /yyyy  \nIf return to work is unknown at this time please provide prognosis:   Follow-up appointment: ☐ None required ☐ As needed Date of next apt.: dd~~ / ~~~~//~~yyyy~~ ~~  \nName of Physician:   Telephone Number:    \nPhysician Signature: ~~ ~~ Date: ~~ ~~dd~~ //~~mm~~ /~~yy~~ ~~  \nSection C-WORKPLACE FUNCTIONAL CAPACITY: This section should only be completed by the Physician when accommodation is requested.  \n\n| Functional Abilities and/or Limitations:  If your patient is able to remain or return to work but has any limitations, please provide the Nature of Condition and complete the applicable sections below. DO NOT include any technical or medical details such as diagnosis or symptoms. Provide a plain language general statement of the person’s illness or injury.\u003Cbr>Nature of Condition: ~~ ~~ |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Walking:\u003Cbr>☐ Full abilities\u003Cbr>☐ Up to 100 metres\u003Cbr>☐ 100-200 metres\u003Cbr>☐ Other |  | Standing:\u003Cbr>☐ Full abilities\u003Cbr>☐ Up to 15 minutes\u003Cbr>☐ 15-30 minutes\u003Cbr>☐ Other |  | Sitting:\u003Cbr>☐ Full abilities\u003Cbr>☐ Up to 30 minutes ☐ 30 minutes-1 hour\u003Cbr>☐ Other |  | Lifting from floor to waist:\u003Cbr>☐ Full abilities ☐ Up to 5 kgs\u003Cbr>☐ 5-10 kgs\u003Cbr>☐ Other |  | Lifting from waist to shoulder:\u003Cbr>☐ Full abilities ☐ Up to 5 kgs\u003Cbr>☐ 5-10 kgs\u003Cbr>☐ Other |  | Stair climbing:\u003Cbr>☐ Full abilities\u003Cbr>☐ Up to 5 steps\u003Cbr>☐ 5-10 steps\u003Cbr>☐ Other | Ladder climbing:\u003Cbr>☐ Full abilities\u003Cbr>☐ 1-3 steps\u003Cbr>☐ 4-6 steps ☐ Other |\n| ☐ Bending, twisting repetitive movement of (please specify) | ☐ Work at or above shoulder activity |  | ☐ Limited use of hand (s):\u003Cbr>Left Right\u003Cbr>☐ Gripping ☐☐ Pinching ☐☐ Other ☐ |  | Limited pushing/pulling with:\u003Cbr>☐ Left arm\u003Cbr>☐ Right arm\u003Cbr>☐ Other |  | ☐ Potential side effects from medications (please specify) Do not include names of medications |  | Cognitive/Psychological:\u003Cbr>☐ Difficulties performing simple and repetitive tasks ☐ Problems maintaining focus/concentration on the job ☐ Limited ability to perform complex and varied tasks ☐ Reduced energy and pace required for the job ☐ Difficulty maintaining healthy co-worker relationships |  |  |\n| Additional Comments on limitations:  \u003Cbr>From the date of this assessment, the above will apply for approximately: ☐ 1-2 days ☐ 3-7 days ☐ 8-14 days ☐ 14+ days\u003Cbr>Physician’s Signature:   Date:   |  |  |  |  |  |  |  |  |  |  |  |\n\nInstructions for Completion  \nFor absences of five working days or longer, have your Physician complete this UWaterloo Sick Leave/Return to Work form. In some cases, managers may (in consultation with Human Resources) request employees to provide the UWaterloo Sick Leave/Return to Work form for shorter absences.  \nOnc","cbCaibctkhScF6ae","https://ap.wps.com/l/cbCaibctkhScF6ae","pdf",431669,"English","# Section A - Employee Details\n# Section B - Sick Leave Details (Physician to Complete)\n# Section C - Workplace Functional Capacity\n# Instructions for Completion\n## Employee’s Responsibilities\n## University’s Responsibilities\n## Guidance for Physicians","[{\"question\":\"What is the purpose of the UWaterloo Sick Leave/Return to Work form?\",\"answer\":\"It provides general information about abilities and limitations to support planning an early and safe return to work, including administering sick leaves, managing return to work, and developing reasonable accommodation solutions.\"},{\"question\":\"Which sections should be completed by the employee and by the physician?\",\"answer\":\"Employees complete Section A (Employee Details). Physicians complete Section B (Sick Leave Details) and complete Section C only when accommodation is requested.\"},{\"question\":\"What information should be avoided when completing Section C?\",\"answer\":\"Section C should not include technical or medical details such as diagnosis or symptoms; it requires plain-language statements of illness or injury and work-related functional limitations.\"}]","Sick Leave/Return to Work Form - UWaterloo | PDF",1789502543]