Get Treatment Memorandum & Functional Abilities Report - Remotesupport Niagararegion

Filling out the TREATMENT MEMORANDUM & FUNCTIONAL ABILITIES REPORT is an essential step for employees seeking support for workplace accommodations or sick leave benefits. This guide will help you navigate the form effectively, ensuring all necessary information is provided for a smooth process.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the TREATMENT MEMORANDUM & FUNCTIONAL ABILITIES REPORT and open it in your document editor.
2. In Section A, fill in the required fields, including your name, employee number, job title, work location, and supervisor's name. Make sure to complete all sections marked by a ‘*’ to ensure your submission is approved.
3. Proceed to Section B, where your health care professional will complete an assessment of your abilities and restrictions. They should indicate whether you can return to work with or without restrictions, or if you are unable to return to work at this time.
4. In Section 2 of Section B, the health care professional must describe your abilities and restrictions in detail. This includes specific assessments for walking, standing, sitting, lifting, pushing/pulling, and cognitive/emotional restrictions. Ensure the health care professional checks all applicable boxes.
5. In Section C, your health care professional will provide information regarding the nature of your illness or injury, the date of assessment, and other relevant details. They will also need to confirm whether this is work-related or not.
6. The health care professional's signature and contact information are required at the end of Section C. They must also confirm if they will continue to treat you or if a referral to another professional has been made.
7. In Section D, as the employee, you must authorize the release of your medical information to the Niagara Region. Complete all necessary fields, including your signature and the date.
8. Finally, review everything for accuracy. Once completed, you can save the changes, download the form, print it, and share it as instructed.

Begin completing your TREATMENT MEMORANDUM & FUNCTIONAL ABILITIES REPORT online today to ensure your benefits and accommodations are processed efficiently.