Return-to-Work Status
|Return form to: | |RETURN-TO-WORK STATUS |
| | | |
| |
|Worker’s name: | |Claim number (if known): | |
|Next scheduled appointment date: | | |
|Is the worker expected to materially improve from medical treatment or the passage of time? Yes No |
| |
|WORK STATUS (Select one option) | |
| | |
| | |
| |OPTION 1 – Released to Regular Work |
| | |
| |OPTION 2 – Not Released to Work |
| | |
| |OPTION 3 – Released to Modified Work |
| |Total work hours: | |hours/day |
| |Lift/carry/push/pull restrictions |
| | |
| | Stand: | |hrs./day |
| | Fine actions: | |
| |Notes / other restrictions: | |
| | |
|Medical provider’s signature: | |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- here is a draft letter you can use to request approval
- post closing escrow agreement seller buyer
- reasonable accommodation agreement sample letter
- sample permission request and release letters
- microsoft word new state of nebraska rtwp
- return to work status
- return to work form university of edinburgh
- letter advising employee they have exhausted
- installation back out and rollback plan template
Related searches
- printable return to work note
- blank return to work form
- return to work form template
- free return to work form
- medical return to work letter
- return to work form printable
- return to work form
- physician return to work form
- medical return to work form
- sample return to work letter
- return to work letter
- return to work letter from doctor