Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:Whole body Hand/arm Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (specify): Use of hand(s): Left Hand Gripping Pinching Other (specify): Right Hand Gripping Pinching Other (specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Yes No Ability to drive car Yes No Attention and Concentration: Full Abilities Limited Abilities Comments: Following Directions: Full Abilities Limited Abilities Comments: Decision- Making/Supervision: Full Abilities Limited Abilities Comments: Multi-Tasking: Full Abilities Limited Abilities Comments: Ability to Organize: Full Abilities Limited Abilities Comments: Memory: Full Abilities Limited Abilities Comments: Social Interaction: Full Abilities Limited Abilities Comments: Communication: Full Abilities Limited Abilities Comments: Please identify the assessment tool(s) used to determine the above abilities (Examples: Lifting tests, grip strength tests, Anxiety Inventories, Self-Reporting, etc.). Additional comments on Limitations (not able to do) and/or Restrictions (should/must not do) for all medical conditions: From the date of this assessment, the above will apply for approximately: 1-2 days 3-7 days 8-14 days 15 + days Permanent 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 the 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 Please check one: Patient is capable of returning to work with no restrictions. Patient is capable of returning to work with restrictions. (Complete Part 2) I have reviewed Part 2 above and have determined that the Patient is totally disabled and is unable to return to work at this time. Recommended date of next appointment to review Abilities and/or Restrictions: dd mm yyyy

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Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration: Whole body Hand/arm Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work. ONTARIO ENGLISH CATHOLIC TEACHERS’ ASSOCIATION (OECTA) AND AGREED TO BY: THE CROWN Article Description Page Preamble 57 Definitions 57 Article 1 Duration and Renewal 60 Article 2 Total Teaching Experience 60 Article 3 Recognition 62

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify)_ Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:Whole body Hand/arm Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work. PREAMBLE/INTRODUCTION The Peterborough Victoria Northumberland and Clarington Catholic District School Board and the OECTA-PVNC Unit Bargaining Unit are committed to improve student achievement, reduce gaps in student outcomes and increase confidence in publicly funded education.

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): APPENDIX B – ABILITIES FORM Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit ______________________ Ability to drive car Yes No ______________ Yes No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): 28 OSSTF EDUCATIONAL SUPPORT STAFF SUPERIOR GREENSTONE DISTRICT SCHOOL BOARD Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Employee’s Consent: I authorize the Health Professional involved with my treatment to provide to my employer this form when complete. This form contains information about any medical limitations/restrictions affecting my ability to return to work or perform my assigned duties. Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes N Yes N

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