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Employee Return To Work Form
Date
Employee Name Last, First
Employee ID#
Phone
--
Address
Apt/Unit
City, State, ZIP Code
Department
Supervisor/Manager Name
Medical Provider Information
Physician Name
Office Address
Unit/Suite
City, State, ZIP Code
Office Phone
--
Office Fax
--
Date of Exam*
Physician Decision*
Employee may return to work with no restrictions/limitations.
Employee may return to work with the following restrictions/limitations:
Activity/Limits Chart
Activity
Limits
Hours per Day

Lifting

Sitting

Standing

Walking

Specific Conditions to Avoid

Other
Physician Signature and Date*
Employee Signature and Date*

Activity	Limits
Hours per Day
Lifting
Sitting
Standing
Walking
Specific Conditions to Avoid
Other

Employee Return To Work Form