2026/Mar/26 1:50:30PM  16043985614->555-1242 3/0

Mar 26, 2026 01:45 To!'+16045205552 Page: 03/10 From: Foremed'Medical Clinic Fax: 1604398561«
2026/Mar/24.2:02:13 PM Translink 555-4212 416
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DCTIC :.
OCCUPATIONAL FITNESS ASSESSMENT (OFA)
CONFIDENTIAL INFORMATION {To be completed by attending physicton)

Mark Holand £21987
Job Title: Date of Birth:
Guideway Serviceperson

Safety Critical Cisafety Sensitive
Plaase refer to Canadian Rallway Medical Rules Handbaok far Positions Critical to Safe Railway Operations,
$i ralican,ca/publication/canadian-raliway-medicg!-rules-hondboo!

Date of injury/tliness: {4 Siw 202 Gccupitionst G Non-Occupstional

General Nature of Iiiness/injury (specific diagnosis not required):
Aapishon Lia Seno; Paw appebte Bote (ars he

Secondary Nature of tltness {if any):

is there a recommended Treatment Plan: wots Cl No
Patlentis compliant with Recommended Treatment: ates OQ No

Date of most recent visit; _! myiaua 202 No

Next plannedvisit: ZIP-T A 2OZ ,

Is your patient taking any medication that could impact their ablifty ta perform work safely and
productively?

meres © No

If so, please explain prikations png restrictions;

1 Cu Ee ch ercise tdlerent

Othes Referred Treatment Providers (ifany): —
iat. eu ~wlwo Ens |
(Or kn aos oR Cadeen ArHiwal) Coe rena SAAD)
is the patient medically cleared ta return to full dutles without any limitatlan and restriction?

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