Return to Work

Employee Name
Date of Surgery

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Work Restrictions Options
No Restrictions Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Unable to Return to Work Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
# of Hours
Reduced Schedule Begin Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reduced Schedule End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Restricted Begin Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Restricted End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Standing (number of hours)
Walking # of Hours
Sitting (number of hours)
Lifting (number of pounds)
Carrying (number of pounds)
Use of Hands
Other Restrictions
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please contact our offices if you have any questions

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Healthcare Professional
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