CDOT Form 628 "Workers' Compensation - Work Status Report" - Colorado

What Is CDOT Form 628?

This is a legal form that was released by the Colorado Department of Transportation - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2003;
  • The latest edition provided by the Colorado Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of CDOT Form 628 by clicking the link below or browse more documents and templates provided by the Colorado Department of Transportation.

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Download CDOT Form 628 "Workers' Compensation - Work Status Report" - Colorado

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COLORADO DEPARTMENT OF TRANSPORTATION
Press firmly or type
WORKERS' COMPENSATION - WORK STATUS REPORT
Employee's Section (return the white & canary copies of this report to your supervisor)
Employee's name (print)
SSN#
Injury date
Physician's name (print)
Physician's phone number
Workers' comp claim # (if known)
Physician's address (print)
Medical services requested
}
Injury treatment
with:
Designated physician
Designated physician referral
Physical therapy
other:
Follow up treatment
Are you currently working:
No
Yes, if yes:
Full duty
Modified duty
I authorize this medical facility to release information about this injury or illness to my employer or to my employer's
workers' compensation insurance carrier in compliance with the Health Insurance Portability and Accountability Act
(HIPAA) Standards for Privacy of Individually Identifiable Health Information under 164.512 (l).
Signature
Date
Physician's section (complete this section - *this section must be filled in - retain pink copy for your records)
Diagnosis and Treatment Plan
To the best of my knowledge and experience this medical condition is consistent with the injury as described by the
employee
Yes
No
Cannot determine
Return to work on
Work status
approximately: (date)
Cannot operate the following equipment:
return to work with no restrictions
_____________________________________
return to work with the following restrictions:
_____________________________________
No climbing (ladders, racks, etc.)
_____________________________________
No lifting more than _________ lbs.
_____________________________________
No driving
*Next appointment
Avoid work environment temperatures
Keep injury clean and dry
scheduled:
(date & time)
greater than _______ or less than______
No:
walking
standing
sitting more
Other restrictions:
than _________ hours per shift.
_____________________________________
No:
pushing
pulling over_________ lbs.
_____________________________________
No reaching:
above chest
over head
away from body
Additional comments:
Date
Physician's signature
Previous editions are obsolete and may not be used
CDOT Form #628
6/03
White - Risk Management
Canary - Supervisor
CONFIDENTIAL/Workers' Compensation Medical Records
Pink - Employee
Goldenrod - Physician
COLORADO DEPARTMENT OF TRANSPORTATION
Press firmly or type
WORKERS' COMPENSATION - WORK STATUS REPORT
Employee's Section (return the white & canary copies of this report to your supervisor)
Employee's name (print)
SSN#
Injury date
Physician's name (print)
Physician's phone number
Workers' comp claim # (if known)
Physician's address (print)
Medical services requested
}
Injury treatment
with:
Designated physician
Designated physician referral
Physical therapy
other:
Follow up treatment
Are you currently working:
No
Yes, if yes:
Full duty
Modified duty
I authorize this medical facility to release information about this injury or illness to my employer or to my employer's
workers' compensation insurance carrier in compliance with the Health Insurance Portability and Accountability Act
(HIPAA) Standards for Privacy of Individually Identifiable Health Information under 164.512 (l).
Signature
Date
Physician's section (complete this section - *this section must be filled in - retain pink copy for your records)
Diagnosis and Treatment Plan
To the best of my knowledge and experience this medical condition is consistent with the injury as described by the
employee
Yes
No
Cannot determine
Return to work on
Work status
approximately: (date)
Cannot operate the following equipment:
return to work with no restrictions
_____________________________________
return to work with the following restrictions:
_____________________________________
No climbing (ladders, racks, etc.)
_____________________________________
No lifting more than _________ lbs.
_____________________________________
No driving
*Next appointment
Avoid work environment temperatures
Keep injury clean and dry
scheduled:
(date & time)
greater than _______ or less than______
No:
walking
standing
sitting more
Other restrictions:
than _________ hours per shift.
_____________________________________
No:
pushing
pulling over_________ lbs.
_____________________________________
No reaching:
above chest
over head
away from body
Additional comments:
Date
Physician's signature
Previous editions are obsolete and may not be used
CDOT Form #628
6/03
White - Risk Management
Canary - Supervisor
CONFIDENTIAL/Workers' Compensation Medical Records
Pink - Employee
Goldenrod - Physician