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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:
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MotionRestrictions:
□OtherRestrictions:
Theselimitations/restrictionsare:
□Temporarylimitations/restrictionsthrough________.
□Permanentlimitations/restrictions
IFTHEABOVERESTRICTIONCONSTITUTEMODIFIEDDUTYANDSUCHDUTYISNOT
AVAILABLE,ITISASSUMEDTHATTHEEMPLOYEEWILLBESENTHOMERATHERTHANRETURN
TOWORK.
MysignatureindicatesthatIhavereadandunderstandtheemployee’sjobdescriptionandthe
listedtaskswithinthejobdescriptionandthatmyfindingsarebasedonmymedical
assessmentofthisemployee’sabilitytoperformthejobduties.
Physician’sName(PleasePrint):
Physician’sSignature:
Date:
IAGREETHAT:
Iwillfollowthroughwithalloftherestrictionslistedabove.Iwillnotifymysupervisorof
anydeparturefromtheserestrictions.
Employee’sSignature:
Date:
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