• Employee Return To Work Form

• 
  
• Date
• Employee Name Last, First
• Employee ID#
• Phone

  --
• Address
• Apt/Unit
• City, State, ZIP Code
• 
  
• Department
• Supervisor/Manager Name
• 
  

• ---

• Medical Provider Information

• Physician Name
• Office Address
• Unit/Suite
• City, State, ZIP Code
• Office Phone

  --
• Office Fax

  --
• Date of Exam*
• Physician Decision*

  Employee may return to work with no restrictions/limitations. Employee may return to work with the following restrictions/limitations:
• Activity/Limits Chart

  Activity	Limits
  Hours per Day
  Lifting
  Sitting
  Standing
  Walking
  Specific Conditions to Avoid
  Other

• Physician Signature and Date*
• Employee Signature and Date*