Return to Work Status Form

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RETURN TO WORK STATUS FORM
TO: EXAMINING HEALTH CARE PROVIDER
RE:
_________________________
Name of Employee
FROM: _______________________________
_________________________
Name of State Agency
Employee ID #
It is our desire to assist our employee and your patient to return to work as soon as possible and to assist him/her in
performing essential job functions at this agency. The information you provide on this form is vital to us regarding the:
A. employee’s working without risk of further injury;
B. provision of a temporary duty assignment if necessary that meets the employee’s needs and the needs of this agency;
C. provision of any temporary reasonable accommodations to aid the employee in performing his/her duties.
If you have any questions regarding the information requested on this form, please contact:
Carolina Bryan, HR Specialist
(409) 880-8375
Name and Title
Phone Number
TO BE COMPLETED BY PHYSICIAN:
(See reverse side for physical requirements of employee’s duties.)
Considering this employee’s job duties and health condition, this employee may perform work in the following manner:
___
FULL DUTY (no restrictions) beginning:
________________
Date
___
TEMPORARY ASSIGNMENT (Modified or Alternate Duty) beginning:
________________
Date
Estimated Length of Temporary Assignment: __________________
Full-Time
Part-Time ( _____ hours per day)
(Please indicate restrictions to duty on reverse side)
___
OFF WORK until re-evaluated, beginning on:
_______________
Date
Date of next office visit:
___________________
Date
__________________________
___________________
Physician’s Signature
Date
FOR AGENCY USE:
Temporary Duty Assignment Begins: __________________
Ends: _________________
Temporary Duty Assignment:
______________________________________________________________________________
The specific duties of the temporary assignment must be provided in a written offer of employment.
EMPLOYEE INSTRUCTIONS:
Return this form to your supervisor immediately after each visit to your health care provider.
Page 1 of 2
RETURN TO WORK STATUS FORM
TO: EXAMINING HEALTH CARE PROVIDER
RE:
_________________________
Name of Employee
FROM: _______________________________
_________________________
Name of State Agency
Employee ID #
It is our desire to assist our employee and your patient to return to work as soon as possible and to assist him/her in
performing essential job functions at this agency. The information you provide on this form is vital to us regarding the:
A. employee’s working without risk of further injury;
B. provision of a temporary duty assignment if necessary that meets the employee’s needs and the needs of this agency;
C. provision of any temporary reasonable accommodations to aid the employee in performing his/her duties.
If you have any questions regarding the information requested on this form, please contact:
Carolina Bryan, HR Specialist
(409) 880-8375
Name and Title
Phone Number
TO BE COMPLETED BY PHYSICIAN:
(See reverse side for physical requirements of employee’s duties.)
Considering this employee’s job duties and health condition, this employee may perform work in the following manner:
___
FULL DUTY (no restrictions) beginning:
________________
Date
___
TEMPORARY ASSIGNMENT (Modified or Alternate Duty) beginning:
________________
Date
Estimated Length of Temporary Assignment: __________________
Full-Time
Part-Time ( _____ hours per day)
(Please indicate restrictions to duty on reverse side)
___
OFF WORK until re-evaluated, beginning on:
_______________
Date
Date of next office visit:
___________________
Date
__________________________
___________________
Physician’s Signature
Date
FOR AGENCY USE:
Temporary Duty Assignment Begins: __________________
Ends: _________________
Temporary Duty Assignment:
______________________________________________________________________________
The specific duties of the temporary assignment must be provided in a written offer of employment.
EMPLOYEE INSTRUCTIONS:
Return this form to your supervisor immediately after each visit to your health care provider.
Page 1 of 2
INSTRUCTIONS TO HEALTH CARE PROVIDER:
The physical requirements below, marked with an “X”, are those required of the employee in performance of his/her
duties. Please mark the indicated column with a response of “Yes” if the employee can accomplish that specific task.
* DUTY Sections– Supervisor indicates with an “X” those that are applicable.
** YES/NO Sections – Marked by Health Care Provider for each duty indicated by supervisor.
DUTY REQUIREMENTS
YES
NO
DUTY
REQUIREMENTS
YES
NO
Heavy lifting, 45 lbs. & up
____
____
Heavy carrying, 45 lbs. & up
____
____
Moderate lifting, 15-45 lbs.
____
____
Moderate carrying, 15-45 lbs.
____
____
Light lifting, up to 15 lbs.
____
____
Light carrying, up to 15 lbs.
____
____
Straight pulling
____
____
Pulling hand over hand
____
____
Repeated bending
____
____
Reaching above shoulders
____
____
Simple grasping
____
____
Dual simultaneous grasping
____
____
Walking
____
____
Standing
____
____
Sitting
____
____
Crawling
____
____
Twisting
____
____
Kneeling
____
____
Pushing
____
____
Stooping
____
____
Climbing Stairs
____
____
Climbing ladders
____
____
Operating mechanical equip.
____
____
Operating office equipment
____
____
Specify: _______________
____
____
Specify: ______________
____
____
Operating a motor vehicle
____
____
Hearing
____
____
Speaking
____
____
Depth perception needed
____
____
Ability to type
____
____
Ability to see
____
____
Ability to write
____
____
Ability to read
____
____
Must be able to intervene with individuals in combative or aggressive situations in an emergency ____
____
Must be able to perform Cardiovascular Pulmonary Resuscitation (CPR) in an emergency
____
____
OTHER ACTIVITIES SPECIFIED BY SUPERVISOR:
_________________________________________________
____
____
_________________________________________________
____
____
PLEASE SPECIFY ANY ADDITIONAL RESTRICTIONS TO DUTY:
____________________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________
________________________________________________________________
Physician’s Name (Printed)
Physician’s Signature
Date
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