Employee Consent Form

This is an example of an Employee Consent Form that can be used by the manager when seeking information from the medical practitioner on the accommodation required to facilitate an employee’s safe return to work. The employee will need to sign this form. Consult the guide for Obtaining Information for Health Care Practitioners in Cases of Employee Illness or Injury for more information on when and how to use this form.

In order to identify my functional abilities, and whether I have any restrictions or limitations that will need to be accommodated in order to help me remain at, or return to work:

I, [employee’s name], authorize [departmental return to work (RTW) point of contact’s name], and [insert telephone number] to contact [print name of physician or health care practitioner] in order to:

  • Request completion of a Functional Abilities Form;
  • Obtain a copy of a completed Functional Abilities Form; and/or
  • Obtain clarification with respect to the restrictions, limitations and/or the duration of restrictions or limitations identified on a Functional Abilities Form.

No diagnosis or treatment information is to be shared with [department].

For the purposes of developing, implementing or seeking approval of a remain-at, or return-to-work plan, and to identify any accommodation measures that may be required, my functional abilities information may be shared among:

  • my supervisor/manager; the unit/local Return to Work Committee (if applicable); the appointed disability management advisor; or authorized human resources officer, within [department]; or
  • my insurer (occupational or non-occupational) if applicable.

Employee’s name: (please print)

Address:

Home Tel:

Work Tel:

Signature:

Date:

Witness name: (please print)

Address:

Home Tel:

Work Tel:

Signature:

Date:

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