Fillable Printable Return to Work Release Form - The University of Texas at Antonio
Fillable Printable Return to Work Release Form - The University of Texas at Antonio
Return to Work Release Form - The University of Texas at Antonio
Return to Work Release Form
The University of Texas at San Antonio
EMPLOYEE INFORMATION
Last Name First Name
Middle Initial
Division, Department or Office
Title / Position
Before an employee may return to work, the return to work clearance process must be fully completed. Based on the employee's current medical examination and the
job description, please complete the following:
Employee can return to work with no restrictions on:
Employee can return to work on:
Other Restrictions
PHYSICIAN'S SIGNATURE (Required)
Signature Date
X
EMPL ID
PHYSICIAN'S STATEMENT
Max hours per day: 0 2 4 6 8 Other
Lift or carry maximum pounds
Bending/Stooping
Walking
Sitting
Climbing
Standing
Reaching above shoulder level
Driving equipment/vehicle
Working with machinery
if the job description is modified with the above restrictions.
Restrictions can be re-evaluated on:
Restrictions will end on:
OR
Employee remains unable to work because of the following reason(s):
Until the following date: (New Return to Work Release form will be required).
06/02/2014 Page 1 of 1 HR-Leave-WorkRelease
Print Name Phone
Fax
Shift Begin Time
Shift End Time
Normal Work Week is
Hours per Day
Days per Week
General Information: This form helps gather return to work information and minimize release of medical information to a supervisor when returning from a leave of absence or use of Sick Leave for an employee's own medical
condition. If an alternate release form is used, please do not include diagnosis or treatment information. This form is submitted by the employee to Human Resources Leave Administration. For more information about
workplace accommodations, contact Annette Rabago, Assistant Vice President Human Resources and UTSA ADA Coordinator at 210-458-4031 or email [email protected]
GINA Notification to Health Care Providers: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of
employees or their family members. In order to comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic information,’ as defined by GINA,
includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information
of a fetus carried by an individual or an individual’s family member or an embryo lawfullyheld by an individual or family member receiving assistive reproductive services.
This form must be submitted to HR Leave department prior to returning to work. (210)-458-4644
