Feel free to copy and paste the information below to use for a physician's recommendations on returning an injured employee to work.
PHYSICIAN’S RETURN-TO-WORK RECOMMENDATIONS
Employee name: __________________________________ Date of injury: _______________
Company name: ______________________________________________________________
Department: _____________________________ Supervisor: __________________________
CHECK THE APPLICABLE BOX BELOW:
Return to work with no limitations as of (date)_______________________________
Return to work with physical restrictions listed below/attached on (date)__________
Date of next doctor’s appointment or return-to-work evaluation: _________________
Approved alternative work assignment: ____________________________________
Unable to return to work at this time:
Date of next doctor’s appointment: ________________________________________
Estimated return-to-work date: ____________________________________________
Physical restrictions:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Other comments (including prescribed medications):
____________________________________________________________________________
____________________________________________________________________________
Physician’s printed name: _______________________________________________________
Physician’s signature: __________________________________________________________
Date: _____________________