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MEDICAL QUESTIONNAIRE

Date: April 2, 2026
RE: MARK HOLAND.
Dear Dr. Ademiluyi,

Thank you for the completion of an Occupational Fitness Assessment on March 26, 2026 regarding Mark
Holand to assist with return to work planning, Within the Occupatlonal Fitness Assessment, physical and
psychological limitations to return to work were Identified as follows:

- Lifting limited to <20lbs

- Walking limited to <30mins

- Agitation, anxiety, Insomnia and poor concentration

+ Communication with colleagues moderate to severely restricted

We require additional information from you regarding the restrictions and Ilmitations mentioned, In
circumstances where an individual is unable to perform the core duties of their position due to a
temporary or permanent disability, BCRTC parties will meet to discuss and consider the available medical
evidence regarding the nature of the disability and, if necessary, options with respect to the
accommodation of the employee, ACRTC will safeguard all madical information received about them in
accordance with applicable privacy legislation,

Helpful terminology used In Occupatlonal Medicine to guide fitness to work:

impalrment: A significant deviation, loss, or loss of use of any bady structure or body function In an
individual with a health condition, disorder or disease.

Limitatton; A limitation Is an activity that a person would be physically or mentally incapable of performing
even if they wanted to perform it because of an impairment.

Restriction: A restriction is an activity that you would not allow a patient to perform, even If that patient
were capable of performing It, becausa of an unacceptable risk resulting from that patlent’s Impalrment.

Please find included the completed Authorization form allowing disclosure of this information to
BCRTC Occupational Health.

Instructlons Physiclan/Health Care Provider;
1. Ensure your patient has completed Employee Consent below. L
2, Complete Occupational Fitness Assessment (OFA) Form.
3. Please return the completed OFA form via fax to 604-520-5552 or via emall to

adebayo_adenekan@berte.be.ca
Billing Instructions

Please fax yourinvalce in accordance with BCMA fee schedule for completion of the attached form
to G04-520- 5552. Please note that we are unable to process an Invoice unless It contains your
involce number and MSP billing number,

Should you require pre-payment, the fee Is paid by the employee and then a receipt may be

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