Medical knowledge, Patient Education
Return to Work
___________________________________________________ was treated at our facility.
Injury or illness was:
___Work-related.
___Not work-related.
___Undetermined if work-related.
Return to work
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Employee may return to work on ______________________.
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Employee may return to modified work on ______________________.
Work activity restrictions
This person is not able to do the following activities:
___Bend
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This person should not sit for more than ____ hours at a time.
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This person should not sit for more than ____ hours during an 8-hour workday.
___Lift more than ________ lb / kg
___Squat
-
___ This person should not stand for more than ____ hours at a time.
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___ This person should not stand for more than ____ hours during an 8-hour workday.
___Climb
___Reach
___Push and pull with the ___ right hand ___ left hand
-
___ This person should not walk for more than ____ hours at a time.
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___ This person should not walk for more than ____ hours during an 8-hour workday.
___Drive or operate a motor vehicle at work
___Grasp with the ___ right hand ___ left hand
___Other _________________________________________________________________
These restrictions are effective until ______________________ or until a recheck appointment on ______________________.
Work modifications
___Need assistive device(s) ______________________________________________
___Other _________________________________________________________________
Health care provider name (printed): _________________________________________
Health care provider (signature): _________________________________________
Date: _________________________________________
How to use this form
Show this Return to Work statement to your supervisor at work as soon as possible. Your employer should be aware of your condition and may be able to help with the necessary work activity restrictions.
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You wish to return to work sooner than the date that is listed above.
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You have problems that make it difficult for you to return at that time.
This information is not intended to replace advice given to you by your health care provider. Make sure you discuss any questions you have with your health care provider.
