Get Physicians Release To Return To Work Form 2016

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. 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 Motion Restrictions Other Restrictions These limitations/restrictions are Temporary limitations/restrictions Permanent limitations/restrictions IF THE ABOVE RESTRICTION CONSTITUTE MODIFIED DUTY AND SUCH DUTY IS NOT AVAILABLE IT IS ASSUMED THAT THE EMPLOYEE WILL BE SENT HOME RATHER THAN RETURN TO WORK. A The above named employee has been released by the above named physician to return to Full Duty as of Date with NO RESTRICTIONS* Date WITH THE FOLLOWING RESTRICTIONS through Date 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. My signature indicates that I have read and understand the employee s on my medical assessment of this employee s physical capabilities as compared to the essential functions of the job. Physician s Signature I AGREE THAT I will follow through with all of the restrictions listed above. A The above named employee has been released by the above named physician to return to Full Duty as of Date with NO RESTRICTIONS* Date WITH THE FOLLOWING RESTRICTIONS through Date 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. My signature indicates that I have read and understand the employee s on my medical assessment of this employee s physical capabilities as compared to the essential functions of the job. Physician s Signature I AGREE THAT I will follow through with all of the restrictions listed above.