Strike Accommodation Survey

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

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* 1. Contact Information:

First Name

Last Name

Address

City/Town

Phone Number

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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?

Yes

No - If no, go to question 9

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* 5. Is this accommodation medically supported?

Yes

No

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

Medical Leave

Short term disability (120 days)

Long term disability (paid by Great West Life)

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

Yes

No

Limited capacity/reduced hours

Other (please specify)

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

Clerical/Office work

Shopping for needed supplies

Driver

Deliveries

General duties as required

Other (please specify)

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

Yes

No

What type of jobs are you able to conduct?

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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?

Clerical/office work

Shopping for needed supplies

Driver

Deliveries

General duties as required