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S-2.1, r. 3 - Regulation respecting the certificate issued for the preventive withdrawal and re-assignment of a pregnant or breast-feeding worker
Schedule
Disposition versions
SCHEDULE I
(s. 1)
PREVENTIVE WITHDRAWAL AND RE-ASSIGNMENT CERTIFICATE FOR A PREGNANT OR BREAST-FEEDING WORKER
SCHEDULE I
(s. 1)
PREVENTIVE WITHDRAWAL AND RE-ASSIGNMENT CERTIFICATE FOR A PREGNANT OR BREAST-FEEDING WORKER
CSST
Commission de la santé et de la sécurité du travail du Québec
Preventive withdrawal and re-assignment certificate for a pregnant or breast-feeding worker
CSST File No.
A- Identification of worker and purpose of consultation
Surname and given name at birth
Medicare number
Social insurance number
Address
Postal Code
Area Code
Telephone number
Application category
Pregnancy
Expected delivery date
Year Month Day
Breast-feeding
Date of birth of breast-fed child
Year Month Day
Nature of the danger apprehended by the worker
Describe:
Signature of worker
B- Identification of workplace and description of worker’s occupation
Employer’s firm name
Address of workplace
Postal Code
Place and department where worker carries out duties
Title of position
Name and position of the person with whom we may communicate in the business
Area Code
Telephone number
C- Compulsory consultation under the Act
(The physician in charge of health services for the establishment need not complete this section if he issues the certificate.)
Name of physician consultant
as x Physician in charge of health services x Head of CHD x Designated physician
Name of community health department
Receipt of consultation report
x by telephone or x in writing
Date
Year Month Day
D- Medical report
In your opinion, what are the working conditions which are physically dangerous to the unborn child or breast-fed child or to the worker because of her pregnancy ?
Is the worker medically capable of working ?
x Yes x No
IMPORTANT
For preventive withdrawal or re-assignment, the worker must be capable of working.
E- Attestation
I certify that the working conditions of the worker are physically dangerous for her because of her pregnancy, or for the unborn child or breast-fed child
For pregnancy only
Indicate the number of weeks of pregnancy at the date of preventive withdrawal of re-assignment
Date of preventive withdrawal or re-assignment
Year Month Day
x Attending physician x Physician in charge of health services
Name of physician (block letters)
Corporation No.
Area code
Telephone number
Signature
Date
Year Month Day
Date certificate delivered to the worker
Year Month Day
Suggestion(s) to employer to facilitate re-assignment (working conditions and duties to be changed).
The worker must return the duly completed certificate to the employer. However, the absence of suggestions made to the employer does not tender the certificate invalid.
Commission de la santé et de la sécurité du travail du Québec
Preventive withdrawal and re-assignment certificate for a pregnant or breast-feeding worker
CSST File No.
A- Identification of worker and purpose of consultation
Surname and given name at birth
Medicare number
Social insurance number
Address
Postal Code
Area Code
Telephone number
Application category
Pregnancy
Expected delivery date
Year Month Day
Breast-feeding
Date of birth of breast-fed child
Year Month Day
Nature of the danger apprehended by the worker
Describe:
Signature of worker
B- Identification of workplace and description of worker’s occupation
Employer’s firm name
Address of workplace
Postal Code
Place and department where worker carries out duties
Title of position
Name and position of the person with whom we may communicate in the business
Area Code
Telephone number
C- Compulsory consultation under the Act
(The physician in charge of health services for the establishment need not complete this section if he issues the certificate.)
Name of physician consultant
as x Physician in charge of health services x Head of CHD x Designated physician
Name of community health department
Receipt of consultation report
x by telephone or x in writing
Date
Year Month Day
D- Medical report
In your opinion, what are the working conditions which are physically dangerous to the unborn child or breast-fed child or to the worker because of her pregnancy ?
Is the worker medically capable of working ?
x Yes x No
IMPORTANT
For preventive withdrawal or re-assignment, the worker must be capable of working.
E- Attestation
I certify that the working conditions of the worker are physically dangerous for her because of her pregnancy, or for the unborn child or breast-fed child
For pregnancy only
Indicate the number of weeks of pregnancy at the date of preventive withdrawal of re-assignment
Date of preventive withdrawal or re-assignment
Year Month Day
x Attending physician x Physician in charge of health services
Name of physician (block letters)
Corporation No.
Area code
Telephone number
Signature
Date
Year Month Day
Date certificate delivered to the worker
Year Month Day
Suggestion(s) to employer to facilitate re-assignment (working conditions and duties to be changed).
The worker must return the duly completed certificate to the employer. However, the absence of suggestions made to the employer does not tender the certificate invalid.
