Injury or Illness Reporting Guidelines Safety Critical Positions (SCP)

Injury or Illness Reporting Guidelines Safety Critical Positions (SCP) INSTRUCTIONS AND RESPONSIBLITIES FOR EMPLOYEES As part of the mandatory Return to Work (RTW) program with Canadian Pacific Railway (CP), employees are responsible for providing information for the provision of suitable modified work. Whether you are injured or become ill while at work or during your personal time, you have an obligation to inform CP if you will be unable to perform your regular work duties and/or anticipate time off work. As a Safety Critical Position employee, you are also required by the Railway Safety Act to advise your Physician or Optometrist and Occupational Health Services of any medical condition(s) or medication(s) that may affect your ability to work safely. 1 2 3 4 5 6 7 Immediately (at your earliest opportunity or by the end of your shift) report to your supervisor/front line manager. Ensure that you obtain the Safety Critical Functional Abilities Form (FAF) from your manager or download and print off the Safety Critical FAF from the Return to Work Packages found online at: http://intranet.cpr.ca/employees/return-to-work OR http://www.cpr.ca/en/employees/return-to-work Seek immediate medical attention for assessment, care and treatment with a Physician. Take the FAF to this initial appointment and ensure it is completed. Ensure you advise your Treating Physician that you occupy a Safety Critical Position. Fax the completed FAF within 72 hours of the injury/illness directly to: CP Occupational Health Services at (403) 319-6803. Contact the Return to Work Specialist for assistance with options for suitable safe work duties and return to work (RTW) planning. The RTW Specialist in your region can be found on CP Station at: http://intranet.cpr.ca/employees/return-to-work Work with the RTW Specialist and your supervisors to develop your RTW plan. Contact your supervisor and/or Return to Work Specialist at least once per week for the duration of your absence to provide updates on your functional ability and estimated return to work. Provide updated FAF s and additional medical documentation to Occupational Health Services (OHS) upon request, and participate fully with RTW planning. Continue to perform modified duties within your documented limitations to the best of your ability, and discuss any concerns with your local RTW Specialist and supervisors. Revised July 28 2015

LETTER TO TREATING PHYSICIAN FUNCTIONAL ABILITIES FORM (FAF) Dear Treating Physician, At Canadian Pacific (CP), we believe in a safe and timely return to work for our employees. CP has a mandatory Return to Work (RTW) Program to assist injured or ill workers back to pre-injury/illness duties as soon as they are medically able. This program provides suitable modified or alternate duties for employees within their limitations and/or restrictions. CP s RTW Specialists and Occupational Health Services will develop an appropriate RTW plan in conjunction with your patient, supervisors, and the information you provide. Your patient occupies a Safety Critical Position (eg. Locomotive Engineer, Conductor or Rail Traffic Controller, and direct managers of employees in these positions) as defined by the Railway Safety Act and operates or controls the movement of trains. Impaired performance due to a medical condition could result in a significant incident affecting the health and safety of employees, the public, property or the environment. The attached Job Demands Analysis will assist you in understanding the job requirements. Further information can also be found in the Canadian Railway Medical Rules for Positions Critical to Safe Railway Operations. http://www.railcan.ca/publications/rule_handbook As a Physician assessing persons occupying these positions you are responsible under the Railway Safety Act to notify the Railway Company s Chief Medical Officer via CP s Occupational Health Services if an employee has a medical condition that could be a threat to safe railway operations. These conditions are listed in Part 4 of the attached form (Medical Report). At this time, we require your assistance in determining your patient s capabilities for work. Please complete all sections of the attached Functional Abilities Form (FAF) for Safety Critical Positions, provide a copy to your patient and fax the form directly to CP s Occupational Health Services at 1-403-319-6803. If we require further clarification regarding your patient s fitness for work or you are reporting that your patient is totally unfit for any work at any level, including sedentary tasks that only require sitting at a desk, you may be asked to provide additional details regarding your patient s restrictions and limitations. If you have any questions regarding your reporting requirements, completing these forms, or our RTW Program, please contact us at 1-866-876-0879. Canadian Pacific (CP) appreciates your prompt reply to our request. Payment for your time will be issued upon receipt of the completed FAF with the attached invoice. Lisa Trueman Director, Health Services Canadian Pacific

PART 1: INFORMATION FOR THE TREATING PHYSICIAN Your patient occupies a Safety Critical Position (eg. Locomotive Engineer, Conductor or Rail Traffic Controller) and operates or controls the movement of trains. Impaired performance due to a medical condition could result in a significant incident affecting the health and safety of employees, the public, property or the environment. As a Physician assessing persons occupying these positions you are responsible under the Railway Safety Act to notify the Railway Company s Chief Medical Officer if an employee has a medical condition that could be a threat to safe railway operations. 1. Ensure your patient has completed Parts 2 and 3 (Employee Consent). 2. Complete Parts 4 to 8 (Medical Report and Functional Abilities). 3. Fax the completed FAF and invoice to Occupational Health Services (OHS) at (403) 319-6803. PART 2: EMPLOYEE INFORMATION EMPLOYEE NAME: JOB TITLE: MUST BE COMPLETED BY THE EMPLOYEE TELEPHONE NUMBER: EMPLOYEE NUMBER: SAFETY CRITICAL POSITION OR SAFETY CRITICAL CONTINGENCY POSITION NON-OCCUPATIONAL INJURY/ILLNESS OR OCCUPATIONAL INJURY/ILLNESS (WCB) DATE OF INJURY/ILLNESS: IF WORK RELATED, SAP INCIDENT #: SUPERVISOR NAME: SUPERVISOR TELEPHONE NUMBER: PART 3: EMPLOYEE CONSENT MUST BE COMPLETED BY THE EMPLOYEE I authorize the healthcare professional who has signed this form to release to CP, i.e. my supervisor, Return To Work Specialist, Occupational Health Services and, where applicable, the WCB Specialist, any functional limitations and/or restrictions information that is relevant to my return to work. I also authorize my healthcare professional to release to and discuss information concerning my present medical condition, solely, with the office of CP s Chief Medical Officer in OHS. Furthermore, I authorize CP to release Parts 1-3 and 5-8 of this form to the appropriate union representative for the purposes of return to work planning. I also authorize OHS, CP, to release all or a portion of the medical information that is relevant to the adjudication of any benefit claim related to my present medical condition to CP s WCB Specialist and the applicable Workers Compensation Board (WCB) and/or Benefit Carrier. I further authorize OHS to release relevant medical information to CP s Supervisors, where necessary, to manage the employment relationship including investigating misconduct or performance issues, to assess the duty to accommodate and compliance with last chance/reinstatement/employment agreements, or to Industrial/Labour Relations and my Union Representative for the purposes of responding to grievance/arbitration or other proceedings when the information is relevant to the proceeding. Any use and disclosure of my medical information will be in accordance with legal requirements and CP Policy 1804, Privacy of Information. I also consent to receiving correspondence from OHS related to my medical condition(s) and assessments by email. This consent is valid for a period of six (6) months from the date signed below. Any medical information received by OHS will be kept in my confidential occupational health file. I understand that a copy of this consent is as valid as the original. x x x Employee Signature Employee Email Address Witness Signature

PART 4: MEDICAL REPORT PLEASE BE ADVISED, THAT YOU MUST ALSO REPORT IF YOUR PATIENT HAS ANY OF THE FOLLOWING MEDICAL CONDITION(S) OR ANY CONDITION WHICH MAY POSE A THREAT TO SAFE RAILWAY OPERATIONS Significant Hearing or Vision Deficits Epileptic Seizure Mental Health Disorder Cardiovascular Disorder Substance Use Disorder Diabetes Severe Sleep Apnea Opioid Pain Medication Use AND/OR Any other medical condition(s) or medication(s) which may pose a threat to safe railway operations Patient Name: DIAGNOSIS (please be specific): A) B) C) TREATMENT Completed and Current: (indicate dates) Surgery Hospitalization Rehabilitation Program Referrals Investigations Other CURRENT MEDICATIONS: (name, dosage, and expected duration of use) DOB (dd/mm/yy): Reassessment Date: Name: Dosage: Duration: Name: Dosage: Duration: Name: Dosage: Duration: Other(s): EFFECTS ON COGNITION: Please provide your opinion on any adverse effects due to medication(s) AND/OR medical condition(s) as related to: NO YES NO YES Alertness Memory Attention Mood Orientation Psychomotor Functions Judgment If YES to any section, please complete Part 8 In your opinion, is your patient at risk for sudden incapacitation or sudden impairment? NO YES, please explain: IF, in your opinion, this patient is totally unfit to perform any work, including sedentary, non-safety sensitive modified work and/or reduced hours, please explain why: NOTE: In the absence of this information, CP may offer temporary accommodation for non-safety sensitive, sedentary, office type duties. Please append copies of ALL relevant reports from Specialists, laboratory, physiotherapy, x-rays, etc. Physician's name (Print) or stamp: Physician's Signature: Date: Family Physician Specialist (Specify):

Name: PART 5: ASSESSMENT Date of Exam: Due to injury or illness this employee has: Normal Functional Abilities - Fit for Regular Hours and Duties Immediately, or as of Complete Part 7 & 9 (Date) Reduced Functional Abilities Fit for Modified Duties Immediately Complete Part 6, 7, & 9; Complete Part 8 only if applicable Able to work full shift Graduated RTW Duration of modified duties:(days/weeks) Due to injury or illness this employee is: Totally Unfit for any work, including sedentary, non-safety sensitive modified work or work hours. (*See note in Part 4 ) Date of expected ability to RTW and/or Modified Work: PART 6: FUNCTIONAL ABILITIES *Physical Demands Definitions from Dictionary of Occupational Titles A: STRENGTH (Lifting/Pushing/Pulling/Carrying) No Restrictions Heavy Medium Light Sedentary COMMENTS Lifting Floor to Waist L R L R L R L R Lifting Waist to Shoulder L R L R L R L R Lifting Overhead L R L R L R L R Pushing/Pulling L R L R L R L R Carrying L R L R L R L R No Restrictions Constant 67%- 100% Frequent 34-66% Occasional 10-33% B: UPPER LIMB Overhead work L R L R L R L R Gripping/Pinching L R L R L R L R Other: L R L R L R L R C: LOWER BODY No Restrictions Constant Frequent Occasional Rare Crouching/Kneeling Forward bending Sitting tolerance: Standing tolerance: D: WALKING/ CLIMBING No Restrictions Constant Frequent Occasional Rare Walking tolerance Uneven ground (loose rock, steep slopes, deep snow) Stairs Step Ladders with handrails Vertical Ladders Requires assistance (cane, crutches) YES NO Comments: E: DRIVING VEHICLES: (select all that apply) Fit and able to drive: (as per license) Personal vehicle Company vehicle without passengers (car, pickup truck) Company vehicle with passengers Company commercial (Semi-truck, Bus) Rare <10% Unfit for driving: Recommendation made to Prov. Licensing Authority License suspended by Prov. Licensing Authority F: OPERATING MOVING EQUIPMENT: Fit and able to operate moving equipment Should not operate moving equipment due to: Physical Impairment, or Cognitive Impairment (Complete Part 8) PART 7: PROGNOSIS Complete Recovery Expected: YES NO Date of next appointment/reassessment: Estimated date for full RTW: >3 months of restrictions Permanently restricted Physician's name & address (stamp): Physician's Signature: Physician's Telephone No: Date: FUNCTIONAL ABILITIES FORM (FAF)

Name: FUNCTIONAL ABILITIES FORM (FAF) PART 8: COGNITIVE FUNCTIONAL ABILITIES (ONLY COMPLETE IF COGNITIVE IMPAIRMENT PRESENT) PLEASE COMPLETE EACH SET OF CHOICES BELOW: BEHAVIOURAL DEMANDS ABILITY TO SELF SUPERVISE No limitations Can tolerate infrequent supervision Requires frequent supervision Cannot self-supervise, constant work supervision required ABILITY TO PROVIDE WORK DIRECTION Able to provide work direction and some elements of managing work performance with exclusion of disciplinary action Able to provide work direction to one or more workers Not able to fulfill any supervisory role WORK COOPERATIVELY (Select all that apply) Able to work closely with co-workers only Able to work on independent duties (works in proximity with others) Not able to work within groups of 5 or more Not able to work with others Must work with others COGNITIVE DEMANDS ALERTNESS No limitations Not always fully alert CONCENTRATION Ability to concentrate on or attend to details at a significant level for many tasks or at an intense level for only some tasks Able to concentrate on or attend to details for some tasks, although not at an intense level Unable to concentrate on or attend to details MEMORY Has basic memory ability, can recall moderate amount of information that is applied to work tasks on a regular basis without rigid time constraints Has moderate memory ability, can recall moderate amount of information that is harder to remember because it is infrequently used or because of time pressure Has poor ability to remember information and apply work tasks DEADLINE PRESSURES Capable of moderately fast work pace and occasionally work under time constraints Capable of a moderate work pace and occasionally work under time constraints Likely to have difficulty working quickly or under time pressure RESPONSIBILITY/ ACCOUNTABILITY Able to perform duties with insignificant consequences Serious difficulty with decision making and may make errors in judgment OTHER (Please explain): Physician's name & address (stamp): Physician's Signature: Physician's Telephone No: Date:

PART 9: INVOICE (SCP FAF) On receipt of the completed report, Canadian Pacific Railway agrees to pay to the treating physician a fee of $100 for the completion of this form. This fee is used as a guide. It is appreciated that in some circumstances a greater fee may be appropriate commensurate with the physician s time and the detail of the information provided. In such circumstances, a fee in accordance with the current provincial guidelines for uninsured services would be appropriate. No additional invoice is necessary. Please provide in the space below the person to whom the cheque should be made payable, and the address. PLEASE WRITE LEGIBLY TO ASSIST US IN PROCESSING YOUR PAYMENT TO BE COMPLETED FOR PAYMENT: Name of Patient: Date Form completed: (dd/mm/yy) Payment made payable to: TREATING PHYSICIAN NAME (PRINT): TREATING PHYSICIAN ADDRESS: TELEPHONE: ( ) FAX: ( ) FOR CANADIAN PACIFIC RAILWAY USE ONLY AMOUNT: $100 CANADIAN ACCOUNT:65802 INVOICE #: COCODE: 1000 ORDER # 7005727 ORDER: YES I HAVE READ AND APPROVE ACCORDING TO POLICY 6137 SIGNATURE: