Return To Work Arrangements Page 2
Download a blank fillable Return To Work Arrangements in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Return To Work Arrangements with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3RETURN TO WORK ARRANGEMENTS (cont.)
Medical restrictions
Describe the restrictions on the most recent Certificate of Capacity or from other sources, e.g. phone call with the worker’s treating health practitioner,
other medical information provided by the WorkSafe Agent. What date or for what period(s) do these restrictions apply?
Hours of work
It is recommended that where reduced hours are required the hours are gradually increased where appropriate.
Week 1
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total p/w
Week 2
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total p/w
Week 3
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total p/w
Week 4
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total p/w
Work Location (address, team, department)
Start date
/
/
Supervisor (name, position, phone number)
Review date
/
/
Prepared by (name, position, phone number)
Prepared on (date)
/
/
KEY PEOPLE INVOLVED IN THESE RETURN TO WORK ARRANGEMENTS
Worker I will participate in these return to work arrangements
Name
Phone
Signed
Date
/
/
Return to Work Coordinator I will monitor and review these return to work arrangements
Name
Phone
Signed
Date
/
/
Supervisor I will implement these return to work arrangements in the work area
Name
Phone
Signed
Date
/
/
Treating health practitioner These return to work arrangements are consistent with the worker’s capacity
Name
Phone
Signed
Date
/
/
NOTES/ADDITIONAL INFORMATION
If there is additional information you wish to include in this form, please attach any supporting documentation e.g. medical reports, position descriptions,
photos etc.
Print Form
Page 2 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business