Care Professional to complete. From the date of this assessment, the above will apply for approximately: 6-10 days 11- 15 days 16- 25 days 26 + days Have you discussed return to work with your patient? Yes No Recommendations for work hours and start date (if applicable): Regular full time hours Modified hours Graduated hours Start Date: dd mm yyyy Is patient on an active treatment plan?: Yes No Has a referral to another Health Care Professional been made? Yes (optional - please specify): If a referral has been made, will you continue to be the patient’s primary Health Care Provider? No Yes No 4: Recommended date of next appointment to review Abilities and/or Restrictions: dd mm yyyy Completing Health Care Professional Name: (Please Print) Date: Telephone Number: Fax Number: Signature: LETTER OF AGREEMENT #1 BETWEEN The Council of Trustees’ Associations/ Le Conseil des associations d’employeurs (hereinafter called ‘CTA/CAE’) AND The Ontario Secondary School Teachers’ Federation/ Fédération des enseignantes-enseignants des écoles secondaires de l’Ontario (hereinafter called the ‘OSSTF/FEESO’)

Care Professional to complete. From the date of this assessment, the above will apply for approximately: Fewer than 6 6 - 10 days 11- 15 days 16- 25 days 26 + days Permanently Have you discussed return to work with your patient? Yes No Recommendations for work hours and start date (if applicable): Regular full time hours Modified hours Graduated hours Start Date: dd mm yyyy Is patient on an active treatment plan?: Yes No Has a referral to another Health Care Professional been made? Yes (optional - please specify): If a referral has been made, will you continue to be the patient’s primary Health Care Provider? No Yes No Please check one: Patient is capable of returning to work with no restrictions. Patient is capable of returning to work with restrictions. Complete section 2 (A & B) & 3 I have reviewed sections 2 (A & B) and have determined that the Patient is totally disabled and is unable to return to work at this time. Should the absence continue, updated medical information may be requested after the date of the follow up appointment indicated in section 4. 4: Recommended date of next appointment to review Abilities and/or Restrictions: dd mm yyyy Completing Health Care Professional Name: (Please Print) Date: Telephone Number: Fax Number: Signature: LETTER OF AGREEMENT #1 BETWEEN The Ontario Council of Educational Workers (Hereinafter ‘OCEW’) AND The Council of Trustees Associations (Hereinafter The ‘CTA’) RE: Job Security The parties acknowledge that education workers contribute in a significant way to student achievement and well-being.

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Care Professional to complete. From the date of this assessment, the above will apply for approximately: 6-10 days 11- 15 days 16- 25 days 26 + days Have you discussed return to work with your patient? Yes No Recommendations for work hours and start date (if applicable): Regular full time hours Modified hours Graduated hours Start Date: dd mm yyyy Is patient on an active treatment plan?: Yes No Has a referral to another Health Care Professional been made? Yes (optional - please specify): If a referral has been made, will you continue to be the patient’s primary Health Care Provider? No Yes No 4: Recommended date of next appointment to review Abilities and/or Restrictions: dd mm yyyy Completing Health Care Professional Name: (Please Print) Date: Telephone Number: Fax Number: Signature: LETTER OF AGREEMENT #1 BETWEEN The Ontario Public School Boards’ Association (hereinafter called ‘OPSBA’) AND The Ontario Secondary School Teachers’ Federation (hereinafter called the ‘OSSTF’) RE: SICK LEAVE‌ The parties agree that any current collective agreement provisions and/or Board policies/practices/procedures related to Sick Leave that do not conflict with the clauses in the Sick Leave article in the Central Agreement shall remain as per August 31, 2014. Such issues include but are not limited to:

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Care Professional to complete. From the date of this assessment, the above will apply for approximately: 6-10 days 11- 15 days 16- 25 days 26 + days Have you discussed return to work with your patient? Yes No Recommendations for work hours and start date (if applicable): Start Date: dd mm yyyy Regular full time hours Modified hours Graduated hours Is patient on an active treatment plan?: Yes No Has a referral to another Health Care Professional been made? Yes (optional - please specify): No If a referral has been made, will you continue to be the patient’s primary Health Care Provider? Yes No 4: Recommended date of next appointment to review Abilities and/or Restrictions: dd mm yyyy Completing Health Care Professional Name: (Please Print) Date: Telephone Number: Fax Number: Signature: Please send completed form to CONFIDENTIAL fax 000-000-0000 Health and Wellness Officer Avon Maitland District School Board Back To LETTER OF AGREEMENT #1 BETWEEN The Ontario Public School Boards’ Association (hereinafter called ‘OPSBA’) AND The Ontario Secondary School Teachers’ Federation (hereinafter called the ‘OSSTF’)

Care Professional to complete. From the date of this assessment, the above will apply for approximately: ☐ 6-10 days ☐ 11-15 days ☐ 16-25 days ☐ 26+ days Have you discussed return to work with your patient? ☐ Yes ☐ No Recommendations for work hours and start date (if applicable) ☐ Regular full time hours ☐ Modified hours ☐ Graduated hours Start Date: dd mm yyyy Is patient on an active treatment plan? ☐ Yes ☐ No Has a referral to another Health Care Professional been made? ☐ Yes (optional – please specify): ☐ No If a referral has been made, will you continue to be the patient’s primary Health Care Provider? ☐ Yes ☐ No

Care Professional to complete. From the date of this assessment, the above will apply for Have you discussed return to work with your patient? Yes No approximately:

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