Return To Work

__________________________________________________ was treated at our facility.

INJURY OR ILLNESS WAS:

_____ Work-related

_____ Not work-related

_____ Undetermined if work-related

RETURN TO WORK

  • Employee may return to work on: ____________________

  • Employee may return to modified work on: ____________________

WORK ACTIVITY RESTRICTIONS

Work activities not tolerated include:

_____ Bending

_____ Prolonged sitting

_____ Lifting

_____ Squatting

_____ Prolonged standing

_____ Climbing

_____ Reaching

_____ Pushing and pulling

_____ Walking

_____ Other ____________________

Show this Return to Work statement to your supervisor at work as soon as possible. Your employer should be aware of your condition and can help with the necessary work activity restrictions. If you wish to return to work sooner than the date above, or if you have further problems which make it difficult for you to return at that time, please call us or your caregiver.

_________________________________________

Physician Name (Printed)

_________________________________________

Physician Signature

_________________________________________

Date