Appendix 1: Sample forms

The Sample Medical Absence Form and Sample Medical Ability to Work Form are included in this publication. The Commission developed these forms to assist employers and employees with common medical information issues that arise in the workplace.

  • Employers may provide the forms to employees and ask that their doctors complete them.
  • Employees may use the forms to get information from their doctors for their employers or benefit carriers.
  • Doctors may adapt the forms for use in their practices.

The sample forms:

  • are not intended to replace any medical forms that are required by WCB or a third-party insurer, or employer-prescribed forms for an employer-funded benefit plan.

  • are intended to help small to medium-sized employers who do not have a disability management position to assist managers and employees with such matters.

  • take into consideration the employee's right to privacy as well as the employer's right to all of the information that is reasonably necessary for a proper inquiry into accommodation.

  • will remove the barriers that are created in workplaces by poor medical information, and thereby keep employees on the job.

  • are not required by law in any situation.

The Sample Medical Absence Form provides general information on the employee's absence, doctor's name and medical checkup.

The Sample Medical Ability to Work Form provides more comprehensive information on limitations or restrictions that the employee has upon returning to work. It is intended to ensure that:

  • the employer, not the doctor, decides which modified duties are available, and
  • the doctor's information reflects a functional analysis of the employee's abilities rather than advice about which jobs the employee can do.

SampleĀ Medical Absence Form (pdf)
Sample Medical Ability to Work Form (pdf)

December 2013


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