Instructions:
Immediate supervisor: Give this form to the employee with the employee's up-to-date job description attached.
Employee: Have your health care provider review your attached job description and complete this form. Return the completed form to your supervisor before you return to work.
Health care provider: Please review the attached job description for this employee, complete this form, and return it to the patient.
Employee name: ________________________________________________
Job title: ____________________________________________________
Date the condition began: __________________________________________
Please check one of the following:
- The employee is able to work a full, regular schedule with no restrictions, beginning ___________(date).
- The employee is unable to return to work until __________(date).
- The employee is able to return to work on a reduced schedule for ___ hours a day from _____(date) through_____ (date).
- The employee is able to return to work with restrictions from______ (date) through______ (date).
Please indicate restrictions, if any, below:
Standing (number of hours): ________________________________
Walking (number of hours): _________________________________
Sitting (number of hours): __________________________________
Lifting (number of pounds): _________________________________
Carrying (number of pounds): _______________________________
Use of hands (repetitive motions, pushing, pulling): ___________________________
Other restrictions: __________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Health care provider's signature: ________________________________________
Health care provider's printed name: _____________________________________
Date: ________________________________________
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