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.
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.