Letter to the Treating Physician on the Functional Abilities Form

This is a sample cover letter addressed to the medical practitioner that can be included along with the Functional Abilities Form and Employee Informed Consent Form. This letter explains why the Functional Abilities Form must be completed and how the information provided will be used.

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.

[Date]

[Address]

Re: [Employee’s Full Name]

Dear Dr. [Name of Physician] or To: [Health Care Practitioner],

The [Department / Agency / Organization] is committed to supporting employees to maintain their health, and to recover from illness or injury when it occurs, and are respectful of the principles articulated in Canadian Medical Association policies on the physician’s role in supporting ill or injured employees.  We strive to enable employees to remain-at-work, by accommodating their needs, or to return-to-work as soon as it is medically appropriate in order to facilitate their recovery and maintain their connection to the workplace.

Our employee, [Mr./Ms./Mrs. Last name] has reported that due to [his / her]  illness or injury, [he / she] is limited in [his / her] ability to perform the normal range of activities related to [his / her] work. 

Therefore, I am writing to you as their [manager / supervisor] to request that you complete the enclosed Functional Abilities Form. The [Department / Agency / Organization] will reimburse the employee for professional fees associated with the completion of this form, which do not exceed those suggested by the provincial / territorial medical association for this type of service.

This form provides information on the physical and non-physical capacities [Mr. / Ms ./ Mrs. Last name] requires to effectively perform the duties of [his / her] job as well as the working conditions and any particular risks or stressors of the job. 

We request that you complete the grey shaded areas with a view to providing as much information as necessary to specify [Mr./Ms./Mrs. Last name] functional limitations and restrictions.  This information will enable us, in collaboration with [Mr./Ms./Mrs. Last name], to arrange a reasonable accommodation (e.g. modified/alternate duties and/or work schedule, gradual return to work, adjustments to equipment), if applicable, and ensure a healthy, safe and supportive work environment.

Please do not include any diagnostic or treatment information (including medication). If you require additional information in order to complete the form (e.g. specialist referral(s), diagnostic tests, laboratory analysis, etc.), please complete the form to the best of your ability and advise when this additional information may be available.

The information provided by you in the FAF will only be used to confirm [Mr. / Ms. / Mrs. Last name]’s ability to [remain-at-work / return-to-work] and arrange a workplace accommodation, as necessary.

Thank you for working with us to support [Mr./ Ms. / Mrs. Last name] in [his/her] recovery and to safely [remain-at-work / return-to-work].

Sincerely,

[Manager / Supervisor’s signature]

Manager / Supervisor‘s Name

Title

Address

Telephone Number

Enclosures: Functional Abilities Form

Employee Informed Consent Form

cc. to EMPLOYEE

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