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Metro Home Building Centre – Staff
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    • Section 02
      • Disciplinary Warning Notice Form
      • Manager Safety Performance Review
      • Supervisor Safety Performance Review
      • Employee Safety Performance Review
    • Section 04
      • Bomb Threat / Anonymous Telephone Call Record
      • Fall Arrest System Inspection Form
      • Emergency Response Plan for Employees Requiring Accommodations
      • Harassment Incident Report Form
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      • Hot Work Permit
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    • Section 05
      • Annual Safety Committee Meeting Schedule
      • Safety Committee Meeting Minutes
      • Safety Committees Recommendations to Employer Form
    • Section 06
      • Orientation Checklist
      • Employee Information Form
      • Direct Deposit Agreement Form
      • TD1 – Personal Tax Credits Return
    • Section 07
      • First Aid Treatment Record
      • Refusal of Treatment or Refusal to be Transported to The Hospital Statement
    • Section 08
      • Ladder Inspection Checklist
      • Quarterly Workplace Inspection Checklist
      • Workplace Inspection Report Form
    • Section 10
      • Accident / Incident Investigation Report
      • Accident / Incident Investigation Employee’s Statement
      • Accident / Incident Investigation Witness Statement
    • Section 12
      • Return to Work Plan Monitoring Form
      • Exit Program Form – Injury Management and Return to Work
      • Return to Work Plan
  • Benefits
  • Online Training
  • Metro Home
  • Staff Home
  • Safety
    • Policies
    • Government Regulations
    • Meeting Minutes
    • Inspection Reports
    • Inspection Certificates
    • Guides
    • Posters
    • Responsibilities
  • Vacation Tracker
  • Vacation Board
  • Forms
    • Section 02
      • Disciplinary Warning Notice Form
      • Manager Safety Performance Review
      • Supervisor Safety Performance Review
      • Employee Safety Performance Review
    • Section 04
      • Bomb Threat / Anonymous Telephone Call Record
      • Fall Arrest System Inspection Form
      • Emergency Response Plan for Employees Requiring Accommodations
      • Harassment Incident Report Form
      • Hazard Report Form
      • Hot Work Permit
      • Housekeeping Inspection Form
      • Illness/Injury Reporting Form
      • Lockout Add
      • Lockout Removal
      • Non-Routine Work Form
      • Violence Incident Report Form
      • Work Refusal Form
      • Spill Report Form
    • Section 05
      • Annual Safety Committee Meeting Schedule
      • Safety Committee Meeting Minutes
      • Safety Committees Recommendations to Employer Form
    • Section 06
      • Orientation Checklist
      • Employee Information Form
      • Direct Deposit Agreement Form
      • TD1 – Personal Tax Credits Return
    • Section 07
      • First Aid Treatment Record
      • Refusal of Treatment or Refusal to be Transported to The Hospital Statement
    • Section 08
      • Ladder Inspection Checklist
      • Quarterly Workplace Inspection Checklist
      • Workplace Inspection Report Form
    • Section 10
      • Accident / Incident Investigation Report
      • Accident / Incident Investigation Employee’s Statement
      • Accident / Incident Investigation Witness Statement
    • Section 12
      • Return to Work Plan Monitoring Form
      • Exit Program Form – Injury Management and Return to Work
      • Return to Work Plan
  • Benefits
  • Online Training

Exit Program Form – Injury Management and Return to Work

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Exit Program Form – Injury Management and Return to Work

To be completed with worker preset.
Name of employee(Required)
Date of incident(Required)
Supervisor name(Required)
Date exit form completed(Required)
Type of injury/treatment
(Please check all that apply)

Questions for the Injured Employee

Did you know this program existed prior to your injury?
Was the workplace process fair?
If a WCB claim, did you complete a Worker Incident Report and send it to the WCB?
Did you feel the workplace used a respectful process?
Was WCB involved in this i.e. a claim?
Were modified duties required?
Have you fully recovered from this injury?
Are you successfully returning to your pre-injury job and wage?

Questions for the Employer

Has WCB been notified that this claim is closed?
Date(Required)
Date(Required)
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