Return-to-Work Release Form

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: _____________________________________