Return To Work
__________________________________________________ was treated at our facility.
INJURY OR ILLNESS WAS:
_____ 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:
_____ Prolonged sitting
_____ Prolonged standing
_____ Pushing and pulling
_____ 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)