cupwesttp

December 21, 2012

To Local Presidents

377, rue Bank Street, Ottawa, Ontario K2P 1 Y3 tel.ltel. 613 236 7238 fax/telec. 613 563 7861

Dear Sisters and Brothers:

Subject: Short Term Disability Plan (STDP)

The Urban Collective Agreement was signed today, December 21, 2012.

Please find attached STDP forms for the employee and doctor to be filled out by the member's doctor in the event that she/he gets sick and has to go on the Short Term Disability Plan.

It is advised that the process to get on the STDP will be faster if the member gets these forms filled out in the first visit by her/his doctor in case the illness is predicted to be longer than seven calendar days. Please note that in case of accident or hospitalization there is no waiting period and the payment will start from the first day of accident/hospitalization. Getting forms filled out the first day will expedite this payment as well.

Also please be advised that the elimination of five minute wash up time at the end of the shift will not be effective before January 1, 2013.

More detailed information will follow in the new year.

In Solidarity,

Denis Lemelin National President

Encl.

Irgcope225

Canadan Urion 01 Postal Wor1<ers

Syndicat des travaitIeUIs at travaIeuses des posies

The struggle continues

La lutts continue

CLCICTC • FTO . UNI

CAll ADA :t;, P OSTES

PO $ T (A!IADA

From IInyw/lere ... to anyone

Employee Statement Short-Term Disabil ity Claim

Please complete this form In its entirety as soon as possible to expedite the processing of your dalrn for disabi lity benefits under the Canada Post Shol1"Term Disability Program. A conpleted claim form must be returned with in' 4 days of the start of the disability to avoid interruptions In payments. The completed form should be mailed or faxed directly to;

GREAT-WEST/MORNEAU SHEPELL 50 BURNHAMTHORPE RD W SUITE 316 MISSISSAUGA ON L5B 3(2 Telephone: 1-855-554-3148 Fax: '-877-562-9126

This form is nOl to be used for workplace injurieslilln~sse5. Ask your ream i&3der instead to provide )"00 v";rh the appropriate WeB form.

Employe'" name (la:.t, first. middle miti,1J):

full aodress (~t ri"('t. CIty. rnovmce. pos:.;)1 codel:

Employee ID number: Email.

Home phone number: Alternai<: phone number:

Dale. of Sirlh (r.ld/mm/\'y'/y): Bargilining Agenl (If ilpplKahle)"

Information about your work (please print)

D fulJ-l1ITIe

Flr,,1 oay of ilb~f.'!Ke (od/mm/yyY")'): o Pan-lime

Expec<ed return 10 WOfI:: o Term employee grealer than 6 month~

Job Infe: Demibe your jOb duhes·

Information about your claim (please print)

Is yovr o'lSi)b!hlY tht> rt>Sull 01: D a llOll-\'I'O!1::-retaled 1Il(le~? o a rlon·W<)!k"fd"ied iKc.oenl?

Have you had a similar 01 related condillon? 0 No 0 Yes II ye~. how long ago J

Are you ahle Ie relUf!) 1{) W.:'lrK on modified duties?

Team leader's narne.

Telephone numboc

Da;e <Inti time of (1ccidem (iJ (.IJ)pht:<Julel: Are you seeJ.:l!19 relfnbursemeo: frOIll iI Ihird I)arf)'? D No 0 Yes

Brrefly d~lbe how and ..... here the aCCident happE:lleO

Name o! 1(l51ilullon

lIIane o! wtlru!lInn:

Dale di3chargi::-d tddlmm'Yi'fY):

Page 1 of 2

Income or benefit Information (please print)

Income { Benefit information

HEW£> you appl~ for or are you receil'ing any of the following· Ernploymem InsurancE'

O~ne-il~ P<lyabl£ UIl(I£,r ~IlY tYIll:' of Worl;er·~ COInpffiS" lIQIl Board program (\"1(8 I VI"SIB I cssn

BE;n£'-fns payable from M Olor Vehld e In5>Jrance or other Insural)~t:'

Other

SIan dale l::ud da:e-Amount (In(j I(CI ! ~

P(!I' Wl"..!1: or momh!y)

N01~· FOI IhE du!al O~ of 1'00' cla'n"!. 11 J$ yaelr re)?O"51blhl~ \0 notify Greilt·We,ltlvkKn"aIlShe;>o:ft oi any 1".'011. periCYlTl<':J . ""nether 01 rrot 'IrJ.. ~Iii'/e (etl'lYo:'::I a"l)'w,,~ or lemllnerabor.; Cllid ant' ernploynefll Iflcome pollCf \0 you ~ a re~lt oi WOfl "e1orlTled by you

Are you follow ing .he recommended Ireil1rn .. n;. progrelfl11 0 No DYes

Name (If primary 31l'Jnding ph,.slcianihealth--care praciil ioner:

Dale flf'5ttrealed:

Addre;s:

TelephOf'l>, numb::r:

Canada Post is subject to the Privacy Act and is committed to protecting employee. personal information and managing this information w ith utmost responsibility and care.

You can be sure that any medical iniorma1ion you give to our disability·management providers will be kept strictly confidential and protected from improper and unauthorized use, disclosure, retention and disposal.

I certify that tt,(' il)lOrrnatior'l on this lotln is U1J(.> and complcte, to th(! best oj my I;nowledge. I undc%tand that my claim may be denied Or1~fminated as a resuit 01 m)' prOl'idmg falS!'! . or mll.leadlr,g information, or Omitting pcrtinC'f)!, Information.

I <luthorize my doctor, Gr,eal·WesIlMorfl€ill,l Shepell and lIS itgl'nts (lnd service provIders and ,my person or organization who has relevant pmonal information abClut 1Ili:', i!1dwing health proi'essio' I<IJs ill )(j organizations, 10 /:!xchanye inforrnat ion lor the purpose oj (J?Ii'mllniny ehgibility lor and the adjudkalioll or rny daun. This irXh,J!.Ie the releaSE of any related nedleill mfarmarion, Incluomg but not Ilmlte-d to copi~ oj all consultation repom. clinical notes. lesl results and hospilal re<oms.

I authorize Grea,·We5!lIvIClmedu She~ anti Canitda Pes; 10 exchdnge Information aboul me excep; lor details rela ting to diagnosis, ueaiment or meoka:101l lelel'am 10 ,his claim b l the purpo~ of planning aoo managing my fe-habilitation and rerurn 10 wor~ and lor adminiw';l1ion of the Shon·Term DiSilb~ity ?rogram.

I agree 11".<11 il photocopy 01 thiS aulhollzatton shall be as \·ahd a.~ th@anginal.

I agree 10 ffilmi)urSf' Cal"lilda Pml for any Sh0t1·1erm Di:.ability Program Qverpayme/lis.

Frnploye«s sigrwture: Da;e (cidlmrn.tyyiY);

P;"9f! :?_of 2

From anywhere ... to anyone

Attending Physician's Statement Short-Term Disability Claim

Please complete this form as soon as possible to expedite the processing of your patient's claim for disability benefits under the Canada Post Short-Term Disability Program. It should be completed and re-turned within 14 days from the onset of the disability to avoid interruptions of payment to the employee. The completed form should be mailed or faxed directly to:

GREAT-WEST/MORNEAU SHEPELL 50 BURNHAMTHORPE RD W SUITE 316 MI55155AUGA ON L5B 3(2 Fax: 1-877-562-9126

This form is not to be lISed for workplace injuries/illnesses.

To be completed by patient (please print)

Employee Name (Lim, First. Middle Initial):

Erlployep tD nI.lmbef" E:rnail:

liofTlE' phont' nllmber: Ah:~mate p\,one nUmli@T:

Addr~5 (number. 511i?€:'. ClI\'. rrCMr"lCe, postal (exl",):

Dine of Sinh (tlrlfmmlyyY)'): Bilrgalfllng Agl>()! (if ilPpl!cabl21· Date form prov!dal 10 phYSICi,m Idtilnufl/yyyv):

I hereby authorize the- release of Information hel:::! in my file by the physicia'" nOl~d below 10 Greal-W£Osi/lv1omeau Shepcil OInd its agents OIr1d wrvice prCl'o'iciers for the pUfpose of a~seSSing m)' claim and admini~lerjr;g lhe oi:.abili!y plan regarding this claim. This m~dical information indude~. btr. is oot limited 10 copi~ of cOl"Slllialion repor"u. clinicall"lote~. leSi re;;uhs (Inti hO$pilill ft'col"{h >upponmg this claim. I understand that I am responsible for any costs related 10 the completion of this form.

Employec·s ~i9nfllur~: Dale (ddlmmlyyyy):

To be completed by the attending physician (please print)

Oia;loos.s{es) Of worl:ing dj"9nosisle~):

If psychologlCid, please proVIde DSM IV Al>!$ 1 diagnosis '.md GAF score.

Pnmary Diagnosis; II d1ildbirth. eXp20ed or adual delivery d.lt!'"

1-----------------------1 (od!rnml)"j')'V,. Secondary Diagnosis:

GAf KOI"£O (i l applicable):

Is thE" diagnosed tiisability the. re~uh of. 0 a non-occup.:ltlOnal jllneiS? 0 il non-occupational ilccidenl?

Ha~ Ih .. paiient h~ a similar 0'- relate<5 (ondltion? 0 No 0 Yes If yl!'S. state when and d£OKribe c:ontlilion:

Is ,he condition (omider .. d to be chronic? 0 No 0 Yes

DOl,,,, of first \~II (OOImmlyyyy)

Dale of la~l visit ldd!mrnf\.'YYY):

Adrnilll'd ,0 tlospltai? 0 No 0 Yes

If yt~. what preCipiratt'd ihe ab!.ence from work?

Date fir>l ullilble 1.0 work due IQ present CondlhOn(s} (ddlrnn/yyyy)

Expected date oi return 10 wor~ (dd/mm/ytyy):

Name oj insdtution:

Ho~pitill depMtmern/wartJ atlmlll&! 10

!reatmcnt (currem medication. type:~ of drtl9(~i. oo~age and duration. physiotherapy. other):

PhYSician's acknowledgement and authorization (please print)

the 'nformallon in tlll~ Statement will be I.epl in a ht>alth file with Grl'ili-WestllY1OIlIi!CMJ She-pelr and may Ilt.' acLesseu by the pa:ielli or lhild partie~ to "~)()111 'or tho:.e law Ihe inil.Jfrnalion, I consent to ~lI(h unedited r;,lease of· InlOfll"lclion contilinl:!d h~f ",in

Addr~~s (nurn/)f;r. \lrl:'£O" ( tt y, proVince, po~l aj (ooe): Telephone numb<.-r:

Signalure

NOTE If not,

If the disability is anticipated to be resolved within two weeks of its onset, no further information is required. section D.

Page 1 o f 2

Additional information for absences known/expected to exceed two weeks (please print)

Oescllbe Ihl' employe?'s ConOt\IQll In U!flns of sympiomologV ~ven1y and frequency). obj2C1ivt.' hrt(fm9~ ilnd imp:Jct on activrtH!5 of daily lil/lng.

rr .. q~lency 01 ,,'SI!S D W~kl¥ D MOllihly 0 Other

i'a:i~t's neigh:: Paticn t'~ W€lght:

1$ <.amplele recov':!(l' eXr)2~led' 0 No 0 Yes, allllClpaled period of re<."OVel)'

Please de~crib~ an}' i a ctor~ thal may a7fed this Daii:::n1's abil ity to retum ,0 wor!:.

Plea5t' anach copies of aU rel .. vam ti'st resultYin~es,i9atiom and (oll5uhai.ion repons!if !5, results all? not a;;ached, II will be assumed Ihai tests v.,I(!rc 001 p..">fiorm.:>d), If a consult,moo repon I~ no, ,1i:iKhed plea5e mdirrne Ii your pauen! r.as or will be Sei!"11 by a 5{)e(iallsl for thIS (ondltlon.

Name of spe(lali:li: Specialty: Date of Visir

Plea~ list any cornpliciii ions and ;,dditional c.onuition(s) impacllng your patient's level 0' function or the expe(teci recovery peliod.

Bi!5ed on your flnding$ and dmlcal observallom, plea!>!;' dE.'s.cribe your pilti .. nt's (Urrt:'nt cognnive andlor physical res,rictlon~ and limlt<Ii!OIlS

Physica l lmpa irm~nt

Does your pallen! have a ph)Sicat impairmeml"

ONO DYes

If yes, please comnlete ihis s::-clicm.

Cognitive/Me ntal impairment

Do.:-s your patlen! hllYe a cognitiwmemall imna,ion?

DNo DYe, Ii yes, please complE'!e this SKlion

Rehabliitation /Work fe-entry

In yOl,r opinion. j~

Has your pa\ient expres,><,d a deslft' to rco,uiTll0 w()fk? D No 0 Yes

own a'icllrs? 0 No 0 Yes

To I"our knnwlecige IS :he piHler,1 fnllowing tloe fei:()fTlmt'ndeo ililalfJlPnl program'} 0 No 0 Yes

HilS your Jlallent"~ pro'e~Slonal licence certi;I«l>IOO, dnver's {II" O!her licence been resUlCted. ~vspended 0/ re .... o~ed? 0 No 0 Yes

E~p&ied dale of return to W01!; \0 full o~lie~ (cd/mrn/yyYYj'

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