Amalgamated Transit Union (ATU) Local 107 - City of Hamilton

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APPENDIX "B"- SHORT TERM DISABILITY CLAIM FORM The City of Hamilton Forward Completed Form to: Mailing Address: Return to Work/Work Accom. Human Resources 71 Main Street West HAMILTON, ON L8P 4Y5 Physical Address Remm to Work/Work Accom. Human Resources Standard Life Building 120 King Street West, 11ÿ' Floor HAMILTON, ON L8P 4V2 Fax : 905-546-4174 Personal information contained on this form is collected under the authority of the Municipal Act, R.S.O. 1990, c. M.45, and will be used a) by the Claims Section, independent medical, or Long Term Disability Carrier to determine eligibility for disability benefits and b) Return to Work/Work Accommodation Services and the Director of Employee and Labour Relations to evaluate work accommodation alternatives. Questions about this collection should be directed to the Director of Employee and Labour Relations . 2. 3. 4. . part of from 6. the the 7. S.T.D. Claims for Income Protection Benefits (Short Term Disability) Instructions: Please Print. Part 1 to be completed by patient. Part 2 to be completed by physician. Any charge for completing this form is the patient's responsibility. Following the claims decision, this document will be forwarded to the appropriate Return to Work/Work Accommodation Specialist and the Director of Employee and Labour Relations, and will become the Employee's confidential health record separate the Employee's personnel file.. Claims Forms are required to be submitted as per Collective Agreement or otherwise as directed by Employer. Both Part 1 and 2 must be completed in full before payments can be authorized PART 1 EMPLOYEE STATEMENT - TO BE COMPLETED PRIOR TO SUBMITTING TO PHYSICIAN (please print) 1. Name: Department: I Employee No: I 2. Start of Present Absence: (day/month/year) Is This Absence a Result of a Workplace Accident/Incident? [] Yes [] No 3. Occupation/Title: Physical Effort Required: [ ] light[ ] moderate [ ] heavy Employee Authorization: The above information is accurate to the best of my knowledge, and I hereby authorize my physician to release the following and subsequent information to the Human Resources Centre in respect to my claim for short term disability benefits. Employee Signature Date: (day/month/year) PART 2 ATTENDING PHYSICIAN'S STATEMENT (incomplete information will result in the Employee being non-paid) (please print) 1. Diagnosis of present condition: (if a psychiatric condition is identified, diagnosis MUST make reference to DSM IV criteria) a) primary b) Additional conditions or complications which might affect duration of absence from work 2. To the best of your knowledge: a) indicate when symptoms first appeared or accident happened (day/month/year) b) has patient had same or similar condition [ ] No [ ] Yes, please state when and describe 3. Is condition due to injury or sickness arising out of patient's employment: [ ] Yes [ ] No [ ] Unknown 4. Date of hospital in-patient admission (day/month/year) Date of discharge (day/month/year) 5. Nature of treatment (e.g. date and type of surgery) 6. a) If patient was referred to you, give name of referring physician, b) If you have referred patient to a specialist, give name(s) of physicians 104
7. a) Date of first visit during present period of absence from work (day/month/year) c) Were you actively supervising this patient's care during the full period [ ] No, comment in remarks [ ]Yes, state frequency of visits []Weekly [ ]Monthly [ ] Other(specify) b) Date of latest attendance (day/month/year) 8. a) To the best of my knowledge, indicate period patient has been unable to work at own occupation as a result of present condition From (day/month/year) To (day/month/year) inclusive b) If still unable to work, give apprx, date patient should be able to return OR the estimated number of weeks before possible return (day/month/year) 9. The Employer has a proactive work accommodation policy. In light of your response to Part 2 No. 8, above, is this Employee capable of performing their regular or modified duties at the present time? [ ] No, (please provide explanation, e.g. nature of restrictions, limitations) [ ] Modified Duties (please provide explanation, e.g. nature of restrictions, limitations) [ ] Regular Duties 10. Remarks - Please provide comments and further details which you feel would be helpful I Name of Attending Physician (please print) Specialty ] Telephone No. Address (number, street, city, province, .postal code) Fax No. Signature Date (day/month/year) 105
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COLLECTIVE BARGAINING AGREEMENT BET
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ARTICLE 36 - ARTICLE 37 - ARTICLE 3
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ARTICLE 4- MANAGEMENT RIGHTS 4.01 T
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(ii) the making of a new agreement.
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The mediator/arbitrator shall endea
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ARTICLE 10 - DISCHARGE CASES 10.01
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12.04 The City (HSR) agrees to pay
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Maintenance/Administrative Employee
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Days off to conduct board sign-ups,
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Plant Electrician Painter Days Mach
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any period or periods of paid absen
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(h) (j) the Employee exhausts these
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(ii) (iii) (iv) (v) (vi) (vii) (vii
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(4) Payments will be made for a max
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agreement. The premiums will be pai
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(b) (c) (d) (e) (f) A disability ca
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without limitation, Long Term Disab
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(iii) (iv) (v) (vi) these benefits
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17.04 17.05 17.06 indexing level of
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NOTE: Work unit seniority within th
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(c) When factor (a) and (b) above a
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First, the lay-off will be offered
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Temporary requirements may be met b
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Work Assignments Operators may work
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Hours of Work Limits Employees may
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examination on their day off. In th
Page 53 and 54: 22.05 MINIMUM PAY VALUE Regular Ope
Page 55 and 56: (b) Call-ins shall be assigned in a
Page 57 and 58: (1) hour, except, in either case, i
Page 59 and 60: (e) Nothing in this Article shall p
Page 61 and 62: entitled to holiday pay as defined
Page 63 and 64: to sign on a blank space but may si
Page 65 and 66: ated over nine (9) months for any u
Page 67 and 68: As the contract for furnishing and
Page 69 and 70: (c) The tool allowances shall be se
Page 71 and 72: each year to each maintenance emplo
Page 73 and 74: ARTICLE 41 - GENDER 41.01 Wherever
Page 75 and 76: GRIEVANCE PROCEDURE In order to ens
Page 77 and 78: 48.02 Where, by the terms of this a
Page 79 and 80: Operator Tire Repairer/Installer Ad
Page 81 and 82: Position Checker Information Clerk
Page 83 and 84: General Repair Shift Foreman/Woman
Page 85 and 86: Shipper/Receiver/Roadsperson Compon
Page 87 and 88: Position Checker Information Clerk
Page 89 and 90: General Repair Shift Foreman/Woman
Page 91 and 92: (b) (c) Benefits -"X" % of Step I B
Page 93 and 94: Approved bridging forms will be sup
Page 95 and 96: volunteer may be contacted. (6) In
Page 97 and 98: emove the employee from the Apprent
Page 99 and 100: seniority shall have no bearing on
Page 101 and 102: INTERIM ASSIGNMENT Upon obtaining h
Page 103: APPENDIX "A"- LIFE INSURANCE Group
Page 107 and 108: (i) (ii) (iii) (iv) your legally ma
Page 109 and 110: Orthodontic Services - Lifetime max
Page 111 and 112: spouse's claim is their own Employe
Page 113 and 114: consideration or laboratory charges
Page 115 and 116: to a nursing home or home for the a
Page 117 and 118: treatment and applicable fees. This
Page 119 and 120: APPENDIX "D" - JOB EVALUATION ATU 1
Page 121 and 122: Whenever HSR decides to establish a
Page 124 and 125: SALARY including: • Salary grade
Page 126 and 127: INDEX A Absent Without Leave (A.W.O
Page 128 and 129: J Job Evaluation ..................
Page 130 and 131: S Safety Footwear Allowance .......
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Amalgamated Transit Union (ATU) Local 107 - City of Hamilton

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