Return To Work Status Form
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1
2RETURN TO WORK STATUS FORM
TO: EXAMINING HEALTH CARE PROVIDER
RE:
_________________________
Name of Employee
FROM: _______________________________
_________________________
Name of State Agency
Employee ID #
It is our desire to assist our employee and your patient to return to work as soon as possible and to assist him/her in
performing essential job functions at this agency. The information you provide on this form is vital to us regarding the:
A. employee’s working without risk of further injury;
B. provision of a temporary duty assignment if necessary that meets the employee’s needs and the needs of this agency;
C. provision of any temporary reasonable accommodations to aid the employee in performing his/her duties.
If you have any questions regarding the information requested on this form, please contact:
Carolina Bryan, HR Specialist
(409) 880-8375
Name and Title
Phone Number
TO BE COMPLETED BY PHYSICIAN:
(See reverse side for physical requirements of employee’s duties.)
Considering this employee’s job duties and health condition, this employee may perform work in the following manner:
___
FULL DUTY (no restrictions) beginning:
________________
Date
___
TEMPORARY ASSIGNMENT (Modified or Alternate Duty) beginning:
________________
Date
Estimated Length of Temporary Assignment: __________________
Full-Time
Part-Time ( _____ hours per day)
(Please indicate restrictions to duty on reverse side)
___
OFF WORK until re-evaluated, beginning on:
_______________
Date
Date of next office visit:
___________________
Date
__________________________
___________________
Physician’s Signature
Date
FOR AGENCY USE:
Temporary Duty Assignment Begins: __________________
Ends: _________________
Temporary Duty Assignment:
______________________________________________________________________________
The specific duties of the temporary assignment must be provided in a written offer of employment.
EMPLOYEE INSTRUCTIONS:
Return this form to your supervisor immediately after each visit to your health care provider.
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