This information will only be used by the CUPE 4222 Executive responsible for coordinating assignments.

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* 1. Contact Information:

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* 2. Job Title:

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* 3. Work location:

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* 4. Are you currently being accommodated by TVDSB on a Return to Work plan?

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* 5. Is this accommodation medically supported?

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* 6. Are you currently on a medical leave, utilizing Short term disability or Long term disability?

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* 7. Are you physically able to support the picket line 4 hours per day, 5 days per week (20 hours)

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* 8. What other duties can you do within your accommodations

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* 9. Do you require accommodation due to religious reasons?

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* 10. Please note: Those who have accommodations, will be accommodated first. If you do not have medical accommodations you may still be required to work on the picket line. What other jobs are you willing to conduct instead of picketing?

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