Employee Return to Work Form - Weber State University
Human Resources 1016 University Circle Ogden, UT 84408-1016 801-626-6032 Fax: 801-626-6925
EMPLOYEE'S RETURN TO WORK FORM
Must be completed legibly by physician
Patient's Name: __________________________________________________Date of Onset: _____________________ Date(s) of Treatment: History: Name(s) of other physician(s) or medical providers who have served on case:
Diagnosis: Treatment (Proposed or completed): Medication(s): Prognosis: First day off work: Actual Return to Work without restrictions: Return to work with reduced schedule:
Number of hours per day: Beginning:
Return to work with the following restrictions:
Lifting (weight)
0-10 lbs.
Lifting
From Floor
25%
From waist level
25%
Over the shoulder/head
25%
Pushing/pulling (weight)
0-10 lbs.
Pushing/pulling frequency
25%
Standing
25%
Sitting
25%
Walking
25%
Climbing
25%
Bending 18"from body
25%
From shoulder level
25%
Over the head
25%
Kneeling/Squatting
25%
No operating moving machinery
No Driving
Additional instruction:
Estimated return to work date:
Number of days per week: Ending:
Beginning: 11-25 lbs.
26-40 lbs.
Ending: 41-50 lbs.
50% 50% 50% 11-25 lbs. 50% 50% 50% 50% 50% 50% 50% 50% 50%
75% 75% 75% 26-40 lbs. 75% 75% 75% 75% 75% 75% 75% 75% 75%
100% 100% 100% 41-50 lbs. 100% 100% 100% 100% 100% 100% 100% 100% 100%
over 50 lbs. over 50 lbs.
Date of next office visit: Physicians Name: City, State, Zip: Telephone Number: Physician's Signature:
Fax Number: Date:
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