Feel free to copy and paste the information below to use for a physician's recommendations on returning an injured employee to work.

PHYSICIAN’S RETURN-TO-WORK RECOMMENDATIONS

Employee name: __________________________________ Date of injury: _______________

Company name: ______________________________________________________________

Department: _____________________________ Supervisor: __________________________

CHECK THE APPLICABLE BOX BELOW:

         Return to work with no limitations as of (date)_______________________________

         Return to work with physical restrictions listed below/attached on (date)__________

            Date of next doctor’s appointment or return-to-work evaluation: _________________

            Approved alternative work assignment: ____________________________________

         Unable to return to work at this time:

            Date of next doctor’s appointment: ________________________________________

            Estimated return-to-work date: ____________________________________________

Physical restrictions:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Other comments (including prescribed medications):

____________________________________________________________________________

____________________________________________________________________________

Physician’s printed name: _______________________________________________________

Physician’s signature: __________________________________________________________

Date: _____________________