USER GUIDE - Vanier College
Contents
1. Axis Il Axis III Axis IV Assessment of illness C Serious _ Moderate L Minor Diagnostic code Diagnostic code Axis V LI I I Secondary illness if any Diagnostic code Frequency of visits First examination for this disability CI Yes Day EDC C No Year From yy a ty Lom y yy da ly Name of physician specialty Pregnancy Is this a serious complication Year Month Month Day Stay in hospital or Clinic Month Day Referral to a specialist specify date of appointment l Result or annex copy Brief report of specific pertinent tests CSF HB ECG EMG CAT MRI AP reading and date etc 2 TREATMENT Medical medication and dosage date of beginning In the case of surgery is the employee able to work while awaiting surgery L Surgical nature and date of surgery Therapy Frequency Name of professional or clinic L Physiotherapy Ll Psychotherapy LI Other specify 3 DISABILITY GRADUAL RETURN TO WORK A Disability definition on previous page ndicate how the illness described above renders the employee unable to hold the position entered in Section A Indicate the functional disabilities definition on previous page Month Day Date of end of period If the absence is extended beyond the date2. of employment regular L Other Where applicable indicate the date of end of employement Employer s no Name of employer 5 M 1792035 VANIER COLLEGE c Q Address 22 821 STE CROIX AVENUE SAINT LAURENT QUEBEC H4L 3X9 Name please print Areacode Telephone no Ext 2 eee 514 744 7500 7203 employer Signature Areacode Telephone no 514 744 7064 Note Please complete Section C Identification of the Employee and indicate the date of end of period agreed to by employer in Subsection D 3 A Section B Attestation and Authorization of Employee to be completed by employee Have you filed or do you intend to file a claim concerning your present disability under a law administered by one of the following organizations If so please check the appropriate box IVAC Indemnisation des victimes d actes criminels SAAQ Soci t de l assurance automobile du Qu bec CSST Commission de la sant et de la s curit du travail RRQ R gie des rentes du Qu bec certify that the information contained in this report is accurate and authorize the physicians and authorized representatives of hospitals and any other organizations concerned to provide the employer and Services conseils aux gestionnaires des r seaux de l ducation with any pertinent information concerning my health condition or medical history with regard to the disability described in this report Upon requ
3. Education 4 Qu bec USER GUIDE DISABILITY MEDICAL REPORT AND SALARY INSURANCE Sections A and C Identification of Employee and Employer Sections A and C must be completed by the employer These sections are for collecting information on the employee and the employer Note on the name of the employer s representative The signatory must be the person designated and authorized by the employer to contact the representative of Services conseils aux gestionnaires des r seaux de l ducation Section B Attestation and Authorization of Employee This section must be completed and signed by the employee If he or she refuses to sign it the employer could reject his or her application for the payment of salary insurance benefits Section D Medical Report The employee must ensure that this section of the form is completed by a physician who is a member of the Corporation professionnelle des m decins du Qu bec CPMQ and who must indicate among other things the diagnosis the date on which the disability began and the expected date of return to work The physician must indicate whether there is any functional disability He or she must also indicate whether there will be a possibility of gradual return to work Subsection 3 A Date of end of period agreed to by employer The employer must enter the date of the end of the disability period to which he or she agreed This date indicates to the attending physician when the em
4. est will submit to the employer the supporting documents attesting to the treatment received from any other health professional for the said disability Year Month Day Area code Home telephone no Signature Date General Information Intended for the Attending Physician and the Employee Claiming Salary Insurance Benefits Salary Insurance Plan The costs related to the salary insurance plan in the education network are assumed in their entirety by the employer for the first 104 weeks of disability This is a self insurance plan to which the employee does not contribute While the employer is responsible for the payment of salary insurance benefits he or she must ensure that the benefits are paid in accor dance with the rules governing the collective agreements in force in the education network The employer may if he or she deems it appropriate require additional information in order to enable him or her to assess the eligibility of the claim as well as any extension of the absence He or she may refer an employee to a physician he or she may designate Any cost related to a medical report such as professional fees or additional information are assumed by the employee unless otherwise stipula ted in the collective agreements or working conditions Definition of Disability To be eligible for salary insurance benefits during a disability period the employee must demonstrate that his
5. ne no Area code Telephone no Address Postal code Specialty if necessary Signature of physician do not use stamp
6. of the period agreed to by the employer agreed to by employer describe the medical reasons or complications justifying the extention CI No Month In your opinion is the employee presently totally unable to perform the usual duties of his or her position Date of beginning Month of disability i Year Day Year Month Day Day Expected date of return to work o If undetermined indicate the approximate date of end of absence D Date of next y appointment B Gradual Return to Work definition on previous page C No Weeks C Yes Days wk Could the employee return to work on a gradual basis If so no of days wk Days wk Weeks Days wk Day and weeks for for for Starting date 4 TOTAL PERMANENT DISABILITY if an In your opinion does the employee exhibit any total permanent disability which prevents him or her from carrying on his or her employment Signature of Physician Only legally authorized physicians may sign the form stamps not accepted If so could the employee carry on other employment Please note that the employer is not bound by the recommendations of the signatory physician Any incomplete report or any report whose content does not support the recommendations could be refused without further notice Name of physician please print Permit no Area code Telepho
7. or her medical condition meets the following criteria 1 the state of incapacity must result from an illness accident pregnancy complication or surgical procedure related to family planning AND 2 the illness or accident necessitates medical care AND 3 the disability must render the employee totally unable to perform the usual duties of his or her position or any other similar position calling for comparable remuneration Definition of Functional Disability A functional disability or incapacity is any restriction resulting from an impairment which significantly limits the employee s ability to per form an activity This indicates what the employee is no longer able to do Gradual Return to Work Any employee may after agreement with the employer benefit from a period of gradual return to work during which he or she must be able to perform all of his or her duties according to the agreed proportion of time Note This document is intended for information purposes only and does not in any circumstances replace or add to the definitions contained in the collective agreements in force in the education network Section C Identification of the Employee Name of employee Social insurance number Section D Medical report to be completed legibly by the physician 1 DIAGNOSIS _ _ o O Main illness causing present disability In the case of a mental disorder fill in the axis according to DSM IV Axis
8. ployer will assess whether the disability is prolonged Should the disability be prolonged the physician must describe the medical reasons or complications in support thereof The costs related to the report are assumed by the employee unless stipulated otherwise in the collective agreements or working conditions If necessary the employer can forward the duly completed form to the person responsible for his or her salary insurance files at the Services conseils aux gestionnaires des r seaux de l ducation at the following address Services conseils aux gestionnaires des r seaux de l ducation Minist re de l ducation 150 boulevard Ren L vesque Est 15 tage Qu bec Qu bec G1R 5W8 Telephone 418 644 8803 Fax 418 646 5424 GENERAL INFORMATION For information on a disability related absence file the person designated and authorized by the employer should contact the representative of the Services conseils aux gestionnaires des r seaux de l ducation who is responsible for this file Education DISABILITY MEDICAL REPORT 4 b Qu ec Salary Insurance Section A Identification of employee and employer to be completed by the employer Family name First name S5 Year Month Day S g Social insurance number Sex Lm L F Date of birth D Address Province Postal code 8 QUE E Date of beginning Year Month Day Job title g of disability Year Month Day Status
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