REQUEST FOR ACCOMMODATION AND REMOVAL FORM SKILL REGISTRATION FORM
......................................................................................................
NOTICE
.......................................................................................................
TO ALL EMPLOYEES, MEMBERS OF THE CARDBOARD AND LABOUR POOL
SUBJECT: PERSONS RETURNING TO WORK FROM STD, LTD OR WCB, ETC…
In order to avoid any unnecessary delays in your return to work please be guided by the following:
At least two weeks prior to your intended date of return to work please provide HEA with a note from your treating physician as to your ability to return to work in the longshoring industry. This should be done regardless of whether or not you require accommodation to facilitate your return.
If temporary or permanent accommodation is required, you will be required to complete a “Request for Accommodation and/or Removal from Skill Registration Form”. A sample of this form is attached. A copy of this form and the HEA’s accommodation policy and procedure is also available on our website at www.halifaxemployers.com.
After receiving advanced notice of an employee’s intent to return to work, the HEA will, within a reasonable period of time, complete their inquiries/assessment through our company doctor, in order to clear the employee for return to work.
It will be necessary that the employee provide a completed “Medical Release Form” to HEA the same day the doctor’s note is provided.
This notice is being distributed to everyone at the Union’s request because we have recently had people delayed coming back into the workforce until they were medically cleared through our company doctor.
If you have any questions please feel free to contact HEA or your Union.
NOTE: Depending on the circumstances, for medical absences of a short duration, a doctor’s note stating you are fit to return to your normal duties is all that may be required.
HALIFAX EMPLOYERS ASSOCIATION ON BEHALF OF:
CERESCORP INCORPORATED
FURNCAN MARINE
HALIFAX OFFSHORE TERMINAL SERVICES LTD.
HALTERM CONTAINER TERMINAL LIMITED
LOGISTEC STEVEDORING INC.
SCOTIA TERMINALS LIMITED
RE-ISSUED: JANUARY 2010
------------------------------------------------------------------------------------------------------------------------------------------------------
REQUEST FOR ACCOMMODATION
AND/OR
REMOVAL FROM SKILL REGISTRATION
Part I Employee Information
Name of Employee or Applicant for Employment:
_______________________ _______________________ ____________________
Name Working Card # (If applicable) Phone Number
Address: ___________________________________________________________________
Street City Postal Code
I am requesting the following accommodation and/or de-registration for the following skills or functions:
________________________________________________________________________________________________________________________________________________________________________________________________
This request is for: Permanent Accommodation and/or Permanent De-registration
Temporary Accommodation and/or Temporary De-registration
If temporary please provide dates: From ____________________ to _____________________
Reason for Request Medical Restrictions/Disability (Attach medical certificate outlining restrictions)
Other
Please Provide Details:
________________________________________________________________________________________________________________________________________________________________________________________________
NOTE: Requests for accommodation or de-registration due to medical conditions or disability require medical certification from the treating physician(s) outlining restrictions and the accommodation sought. The authorization for release of medical information below must be completed and signed. Failure to do so may void this request.
Authorization for Release of Medical Information
I understand that the HEA may request their designated medical physician/practitioner to communicate with the medical physician(s)/practitioner(s) listed below. I hereby authorize the release of any information necessary for the purpose of determining my medical condition as it relates to my employment as a longshoring industry in the Port of Halifax.
______________________________________ __________________________
Signature Date
Dr. ____________________________________________________________________
Name and Telephone Number
Dr. ____________________________________________________________________
Name and Telephone Number
|
