LETTER OF AGREEMENT This agreement is between by va23990

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									                                                    LETTER OF AGREEMENT


This agreement is between .....................................................................................and the Workplace Health
and Public Safety Programme(WHPSP) of Health Canada for the provision on Fitness to Work Evaluations
related to health problems or learning difficulties that could hinder the learning of a second language.

The department/agency agrees to pay the sum of $ 624.00 for a basic assessment (according to costing
template of 2004, price subject to change without prior notice) plus all costs for specialist evaluation, advice
and consultation. The medical evaluation will be conducted according to the Fitness to Work Protocol of the
WHPSP (http://publiservice.gc.ca/services/hecs-sesc/whpsp/pdf/ftwe_e.pdf)


Fitness to Work

This is a four hour(minimum) block of time which includes examination and testing
                                                                                                                          $624.00
(physical and/or psychological), evaluation of test results done internally or externally to
WHPSP, and reporting of the overall evaluation.

Fitness to Work - Requirements for time in excess of 4 hours will be discussed with
requesting authority and pre-authorized




Specialist Evaluation with Testing (e.g. neuropsychological testing; functional abilities
testing)                                                                                                                  at cost
( Prices are dependent on cost of service provider and complexity of case)


                                                                                                                        Based on
Fitness to Work - Follow-up
                                                                                                                      hourly rate of
Re-opening of a closed file by a WHPSP health professional due to a new development
                                                                                                                     service provider


Advisory and Consultation
                                                                                                                        Based on
This includes planning for, delivery of or any activities related to any of the above listed
                                                                                                                      hourly rate of
services. Includes information related to all medicals, tests or immunizations.
                                                                                                                     service provider


Late Cancellation Fee will be charged for failure to cancel service request with at least one working
day’s notice: $75.00 for Fitness to Work and cost of specialist’s time.


Financial code:                                                                  Finance contact:

- Department Number: .................................                           Name :............................
- Organization code: .....................................                       Tel: .................................
- Reference code: .....................................                          Fax: ................................
Once completed, the department will be invoiced directly and will receive a report of the assessment.




For the department:                                          For WHPSP

Name: .......................................                Dr. Eva Callary
Title : .......................................              Medical Officer in Charge
Address: ....................................                Workplace Health and Public Safety Programme
...................................................          171 Slater, Ottawa PL 3712 M
...................................................          K1A 0K9
..........................................................   Tel: (613) 946-6583
                                                             Fax: (613) 990-9397




________________________________                             ____________________________
(Signature)                                                  (Signature)


Date:____________________________                            Date:________________________
For WHPSP (Health Canada):
National Capital Region       171 Slater Street                Dr. Eva Callary,
Ottawa ( Regional Office)     Vanguard Building                Medical Officer in Charge
                              12 th Floor                      Tel: 946-6583 Fax: 990-9397
                              PL 3712 M                        The completed fitness to work package
                              Ottawa ON K1A 0K9                should be sent to the attention of Lisa
                                                               Robinson, Administrative Officer

Atlantic Region               Maritime Centre                  General Inquiries:   (902) 426-9894
Halifax (Regional Office)     1505 Barrington Street           Moncton              (506) 851-7005
                              Halifax NS B3J 3Y6               Charlottetown         (902) 566-8987
                                                               St. John’s            (709) 772-5571
Quebec Region                 11 th floor, Guy Favreau         General Inquiries: (514) 283-2463
Montreal (Regional Office)    Complex - East Tower
                              200 Réné-Lévesque Blvd. West
                              Montreal QC H2Z 1X4              Quebec City            (418) 648-7205
Ontario / Nunavut Region      55 St. Clair Ave. East           General Inquiries: (416) 973-1178
Toronto (Regional Office)     Room 315                         Hamilton           (905) 540-3104
                              Toronto ON M4T 1M2               Kingston           (613) 545-8140
                                                               Sault Ste. Marie (705) 941-3130
Manitoba / Saskatchewan       Room 604, 6 th Floor - Cargill   General Inquiries:(204) 983-6330
Winnipeg (Regional Office)    Grain
                              240 Graham Ave
                              Winnipeg MB R3C 0J7              Regina               (306) 780-6448
Alberta / NWT Region           Room 835, 8 th Floor            General Inquiries: (780) 495-6695
Edmonton (Regional Office)    Canada Place
                              9700 Jasper Avenue
                              Edmonton AB T5J 4C3              Calgary               (403) 292-5525
British Columbia / Yukon      Room 515, Sinclair Centre -      General Inquiries: (604) 666-7310
Region                        Winch Tower
Vancouver (Regional Office)   757 West Hastings Street         Victoria               (250) 363-3566
                              Vancouver BC V6C 1A1

								
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