Employee Return to Work Form
Employee Name: _____________________________________________________
Dates of Absence: _____________________________________________________
Physician Section:
This employee is taking medication that could interfere with his/her ability to safely perform their job.
This employee is not taking medication that could interfere with his/her ability to safely perform their job.
Worker is released for the job with no restrictions.
Worker is
released for the job with the following restrictions:
___________________________
____________________________________________________________________________
Worker is not yet released for the job. Anticipated release date is: ______________________
Worker is NOT released to work. Worker will be reassessed on: ________________________
Comments:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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Physician’s
Name |
Signature |
Date |
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Employee: Return completed form to your Supervisor on your first day back to work.
