Medical Certificate. Absent from Work (first date of absence) Not absent from work but requires accommodations Part 1 – Employee - please complete following: (Employee Name) The information supplied will be used in a confidential manner and may assist in creating a return to work plan. I hereby consent to the completion of this form by: (Treating Medical Practitioner’s Name) (Signature of Employee) (Date)
Appears in 50 contracts
Samples: Agreement, Letter of Agreement, Collective Agreement
Medical Certificate. 🞏 Absent from Work (first date of absence) 🞏 Not absent from work but requires accommodations Part 1 – Employee - please complete following: (Employee Name) The information supplied will be used in a confidential manner and may assist in creating a return to work plan. I hereby consent to the completion of this form by: (Treating Medical Practitioner’s Name) (Signature of Employee) (Date)
Appears in 49 contracts
Samples: Collective Agreement, Waterloo Catholic, Letter of Agreement
Medical Certificate. □ Absent from Work (first date of absence) □ Not absent from work but requires accommodations Part 1 – Employee - please complete following: (Employee Name) The information supplied will be used in a confidential manner and may assist in creating a return to work plan. I hereby consent to the completion of this form by: (Treating Medical Practitioner’s Name) (Signature of Employee) (Date)
Appears in 4 contracts
Samples: Collective Agreement, Collective Agreement, Collective Agreement
Medical Certificate. Absent from Work (first date of absence) Not absent from work but requires accommodations Part 1 – Employee - please complete following: (Employee Name) The information supplied will be used in a confidential manner and may assist in creating a return to work plan. I hereby consent to the completion of this form by: _ (Treating Medical Practitioner’s Name) (Signature of Employee) (Date)
Appears in 3 contracts
Samples: Collective Agreement, Collective Agreement, Collective Agreement
Medical Certificate. Absent from Work (first date of absence) Not absent from work but requires accommodations Part 1 – Employee - please complete following: (Employee Name) The information supplied will be used in a confidential manner and may assist in creating a return to work plan. I hereby consent to the completion of this form by: (Treating Medical Practitioner’s Name) (Signature of Employee) (Date)
Appears in 2 contracts
Samples: www.sdc.gov.on.ca, elemdp.com
Medical Certificate. 🞏 Absent from Work (first date of absence) 🞏 Not absent from absentfrom work but requires accommodations Part 1 – Employee - please complete following: (Employee Name) The information supplied will be used in a confidential manner and may assist in creating a return to work plan. I hereby consent to the completion of this form by: (Treating Medical Practitioner’s Name) (Signature of Employee) (Date)
Appears in 1 contract
Samples: Letter of Agreement
Medical Certificate. 🞏 Absent from Work (first date of absence) 🞏 Not absent from work but requires accommodations Part 1 – Employee - please complete following: (Employee Name) The information supplied will be used in a confidential manner and may assist in creating a return to work plan. I hereby consent to the completion of this form by: (Treating Medical Practitioner’s Name) (Signature of Employee) (Date):
Appears in 1 contract
Samples: Letter of Agreement
