"Return to Work With Restrictions Letter Template"

What Is a Return to Work with Restrictions Letter?

When an employee has been unable to complete their work duties for a period of time, but plans on returning to their position, it is a good idea to complete a Return to Work With Restrictions Letter before they return. An employee may need to take a leave of absence due to a new child, loss of a parent, illness, or injury, but have worked with the company to find a suitable time to return.

This letter will help both the company and the employee understand the role the employee will have once they return and if their normal duties will need to be staggered as they readjust to working again. A Return to Work with Restrictions Letter template can be found through the link below.

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How to Write a Return to Work With Restrictions Letter?

To write a return to work with restrictions letter, you will want to include the following information:

  • Name of Employee;
  • Job Title;
  • The dates the employee will be unable to work;
  • If the employee is full-time or part-time;
  • Statement about why the employee will be unable to perform their work duties and that this arrangement has been authorized by their manager and any higher-ups. Include the specific reason why the employee will be taking a break (for legal documentation purposes), and that the employee acknowledges their work duties will be different once they return;
  • List the person(s) who will be taking over the duties of the employee and which duties will be the employee's again once they return. It will be important to discuss which duties they will be taking back on immediately and when they can expect to be working their former routine again;
  • You will also want to mention if the employee's position will change (such as full-time to part-time) and if that will be a permanent or temporary change;
  • If any benefits or pay will change due to their absence, you will need to include this information so the employee is fully aware before taking their leave (and so the company legal time can document the changes);
  • Signature sections for management and the employee to acknowledge that all parties agree to the leave of absence and restrictions the employee has agreed to once they return.

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Return to Work with Restrictions Letter
From: ​ _ ____________________________
To:​ _ _______________________________
Name of Health Care Provider
Employee’s Name
___________________________________
___________________________________
___________________________________
___________________________________
Address of Health Care Provider
Employee’s Address
___________________________________
___________________________________
City, State, ZIP Code
City, State, ZIP Code
__________________________________
D ate
Dear _____________________________,
Please review the attached job description for this employee, complete this form, and
return it to the patient. The employee is able to return to work with restrictions from
_____________ through _____________.
Date
Date
Please indicate restrictions, if any, below for:
● Standing: ________________________________________;
● Walking: ________________________________________;
● Sitting: ________________________________________;
● Lifting: ________________________________________;
● Carrying: ________________________________________;
● Use of hands: ________________________________________;
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Other restrictions (if any)
©​ ​ ​ ​ ​ ​ ​
T EMPLATEROLLER.COM
Return to Work with Restrictions Letter
From: ​ _ ____________________________
To:​ _ _______________________________
Name of Health Care Provider
Employee’s Name
___________________________________
___________________________________
___________________________________
___________________________________
Address of Health Care Provider
Employee’s Address
___________________________________
___________________________________
City, State, ZIP Code
City, State, ZIP Code
__________________________________
D ate
Dear _____________________________,
Please review the attached job description for this employee, complete this form, and
return it to the patient. The employee is able to return to work with restrictions from
_____________ through _____________.
Date
Date
Please indicate restrictions, if any, below for:
● Standing: ________________________________________;
● Walking: ________________________________________;
● Sitting: ________________________________________;
● Lifting: ________________________________________;
● Carrying: ________________________________________;
● Use of hands: ________________________________________;
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Other restrictions (if any)
©​ ​ ​ ​ ​ ​ ​
T EMPLATEROLLER.COM
Feel free to contact me through my email at [​
E mail​
] or at [​
P hone Number​
] .
Sincerely,
__________________________________
Name of Health Care Provider
__________________________________
Signature of Health Care Provider
©​ ​ ​ ​ ​ ​ ​
T EMPLATEROLLER.COM
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