I N S T R U C T I O N S
To be completed by treating HEALTH CARE PROVIDER
|Print |
|Employee Name: |
| |
|Employee can return to work as of (date): |
|Employee can return with: |
|No limitations/restrictions at this time |
|The following limitations or restrictions |
| |
|Standing: |
|Sitting: |
|Lifting: |
|Carrying: |
|Health Care Provider Signature |Date |
|Print Name |Company/Organization Name |
|Street Address |
|City |State |Zip |
|Phone ( ) |License Number |
NOTE TO EMPLOYEE
TO RETURN FROM YOUR MEDICAL-RELATED LEAVE (if you have been hospitalized or have been off work more than five (5) consecutive work days):
|STEP 1 |Take this RELEASE TO RETURN TO WORK form to your health care provider and have him/her fill out the form COMPLETELY. If |
| |necessary, a form provided by the Health Care Provider is also acceptable. |
| | |
| |For the Provider’s form to be considered, the following MUST be present: |
| |Return to Work Date; |
| |Either the no limitations/restrictions or specific limitations/restrictions box must be checked; |
| |Health Care Provider’s Signature. |
|STEP 2 |ONE WEEK before your return to work date; notify your supervisor if you are returning, or if you are requesting an extension |
| |of your leave. If requesting an extension, you must submit another Request and Response Form with the additional time off |
| |requested. |
|STEP 3 |On your first day back, before beginning work, provide completed RELEASE TO RETURN TO WORK form to Human Resources. You can |
| |do this in person or you may fax a copy of your RELEASE TO RETURN TO WORK to: Human Resources, Fax: (760) 750-4710. |
| |If you or you physicians have any questions, please call Human Resources, (760) 750-4700. |
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