Under the Pour une maternité sans danger program, this certificate attests that a pregnant or breastfeeding worker's job involves physical dangers for the unborn or breastfed child, or for her because of her pregnancy. Handing it to her employer is her request for reassignment to safe tasks; if none is offered, she may stop work under a retrait préventif and receive indemnities. The program is prevention, not maternity leave.
The professional who follows the pregnancy or the postnatal care completes sections A to G: a physician, IPS or midwife (sage-femme), a midwife's postnatal follow-up running up to 6 weeks after birth. The regional public health director or their designee may be consulted, but is not authorized to issue the certificate.
Enter the worker's name at birth, address, health insurance number and telephone. Summarize the dangers she fears in Nature des dangers appréhendés par la travailleuse. Under Catégorie de la demande, tick Grossesse with the expected delivery date and the number of weeks of pregnancy when you issue the certificate, or Allaitement with the breastfed child's date of birth. CNESST and the public health director both rely on these details.
Identify the employer, the workplace address, the workstation and department where she performs her tasks (Poste de travail et service), her job title (Titre de l'emploi), and the name, role and telephone number of a contact person in the company. The job title matters because the DNSP protocols you consult in section D are listed by profession.
Answer Oui or Non to whether the worker is medically fit to do a job. CNESST treats this answer as mandatory, because a worker must be fit for work to benefit from reassignment or preventive withdrawal. CNESST's page for professionals adds that you must examine her and assess her fitness in light of her pregnancy and state of health.
Check the national public health director's (DNSP) protocols, listed by profession at cnesst.gouv.qc.ca/protocoles-pmsd. If one matches her working conditions, enter its number; enter more than one if she holds several job titles with the same employer, then go to section F. If none matches, or no protocol exists for her profession, tick the applicable reason: consultation is then mandatory before you issue the certificate.
Complete only when section D called for a consultation. Enter the name of the physician responsible for the establishment's health services, the regional public health director or their designee, and tick their capacity (En qualité de). Add the Direction de santé publique's name and telephone and the date the rapport médicoenvironnemental was sent to you, and give the worker a copy of that report.
Based on the protocol or rapport médicoenvironnemental, state which working conditions involve physical dangers for the unborn or breastfed child, or for her because of her pregnancy. In light of her health, add any suggestions to the employer to ease reassignment (conditions and tasks to modify); having none does not invalidate the certificate. Last, list any health problems these conditions could aggravate; this answer is masked on the employer's copy.
Tick the statement attesting that her working conditions involve physical dangers for the unborn or breastfed child, or for her because of her pregnancy. Choose Immédiatement or Autre date for the recommended start; it may differ from the protocol's or report's recommendation if her health requires. Add your name, licence number, telephone and title (Médecin, Infirmière praticienne spécialisée or Sage-femme), sign, date, and record the date given to the worker if different.
Download the current version from the source each time; forms change without notice.
Certificat visant l'affectation ou le retrait préventif de la travailleuse enceinte ou qui allaite
Certificate for Reassignment or Preventive Withdrawal of a Pregnant or Breastfeeding Worker
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Sources for this guide
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The professional who follows the pregnancy or postnatal care: a physician, a specialized nurse practitioner (IPS) or a midwife (sage-femme), who can provide postnatal follow-up up to 6 weeks after birth. The regional public health director or their designee may be consulted and may produce a rapport médicoenvironnemental, but is not authorized to issue the certificate.
Before issuing the certificate, you must consult the physician responsible for the establishment's health services or, failing that, the public health director of the region where the establishment is located, or their designee. Tick the reason in section D, record the consultant and the date the rapport médicoenvironnemental was sent in section E, and give the worker a copy of that report.
Yes. A worker who used the program during pregnancy must start the process again for breastfeeding. The professional following the postnatal care completes and signs a new certificate, ticking Allaitement and entering the breastfed child's date of birth, and only dangers that could harm the breastfed child are then taken into account.
No. The downloadable PDF is marked MODÈLE and is for reference only; CNESST requires you to order and use the certificate it prints. The set has copies for the professional, the worker and the employer, filled in with a pencil or hard-tip pen pressed firmly, and the employer's copy leaves out the confidential medical information.