Fillable Printable Physician's Release to Return to Work Form

Physician's Release to Return to Work Form

PHYSICIAN’S RELEASE TO RETURN TO WORK FORM

Employee’s Name: Date:

Physician’s Name: Telephone #:

To be completed by Physician

After reviewing the attached job description and the specific tasks within the

job description please complete either (A) or (B) as appropriate and sign and

date below.

(A) The above named employee has been released by the above named

physician to return to Full Duty as of _______________(Date)

with NO RESTRICTIONS.

(B) The above named employee has been released by the above named

physician to Return to Work on ___________(Date) WITH THE

FOLLOWING RESTRICTIONS through __________(Date):

Check applicable boxes and provide limitations/restrictions.

 Lifting (Max weight in lbs) _________lbs.  Walking ___________ hours per day

 Repetitive Lifting ___________lbs.  Standing ___________ hours per day

 Carrying _____________lbs.  Sitting ___________ hours per day

 Pushing/pulling ___________lbs.  Crawling ___________ hours per day

 Pinching/Gripping ___________lbs.  Kneeling ___________ hours per day

 Reaching over head  Squatting ___________ hours per day

 Reaching away from body  Climbing ___________ hours per day

 Repetitive Motion Restrictions:

 Other Restrictions:

These limitations/restrictions are:  Temporary limitations/restrictions

 Permanent limitations/restrictions

IF THE ABOVE RESTRICTION CONSTITUTE MODIFIED DUTY AND SUCH DUTY IS NOT

AVAILABLE, IT IS ASSUMED THAT THE EMPLOYEE WILL BE SENT HOME RATHER THAN

RETURN TO WORK. My signature indicates that I have read and understand the employee’s

job description and the listed tasks within the job description and that my findings are based

on my medical assessment of this employee’s physical capabilities as compared to the

essential functions of the job.

Physician’s Name (Please Print):

Physician’s Signature: Date:

I AGREE THAT:

I will follow through with all of the restrictions listed above. I will notify my supervisor of

any departure from these restrictions.

Employee’s Signature: Date: