Attending Physician's Statement – Restricted Duty Form



|[pic] | |

| |Sample: Early Return to Work - Modified Duty Opportunity Form |

|Modified Duty Activity Name: |

|Description of employee’s modified responsibilities: |

| |

| |

| |

|Projected duration of modified assignment: (not to exceed 60 days without physician and executive management review): |

| |

| | |Occasional |Frequent |Continuously |Never |

|Estimated Activity time per work day |30 mins. to 2.5 |2.5 to 5.25 |More than 5.25 |0% |

| |hrs/day |hours/day |hours/day | |

|A. Lifting |0-10 lbs. ___ times per hour. | | | | |

| |11-20 lbs. ___ times per hour.| | | | |

| |21-50 lbs. ___ times per | | | | |

| |hour. | | | | |

|B. Pushing/Pulling |0-10 lbs. ___ times per hour.| | | | |

| |11-20 lbs. ___ times per | | | | |

| |hour. | | | | |

| |21-50 lbs. ___ times per | | | | |

| |hour. | | | | |

|C. Sitting | | | | |

|D. Standing | | | | |

|E. Walking | | | | |

|F. Bending/Stooping (at waist) | | | | |

|G. Squat/Crouch/Kneeling/Crawling | | | | |

|H. Overhead work | | | | |

|I. Driving | | | | |

|J. Other: | | | | |

|K. Other: | | | | |

| |

|Company Contact:__________________________________________ Phone #: ____________________________________ |

| |

|Date: ____________________________________ |

|Review & Approval: |Review & Approval: |

| | |

|_________________________ ______________ |_________________________ ______________ |

|Name/Title Date |Name/Title Date |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download