Physician'S Release Return To Work Form "With" Or "Without" Restrictions printable pdf download

Physician'S Release Return To Work Form "With" Or "Without" Restrictions

YUBA COUNTY PHYSICIAN’S RELEASE

RETURN TO WORK FORM “WITH” or “WITHOUT” RESTRICTIONS

Employee Name:

TO BE COMPLETED BY HEALTH CARE PROVIDER:

The above employee is hereby released to restricted duty on

(Date), as

s/he is able to perform the essential job functions as recorded on the accompanying “Class

Specification” with restrictions as described below. (ex. unable to lift more than 15 lbs,

alternate sit/stand, no stooping/bending, may not rotate torso beyond 40 degrees, can only

work 4 hours a day, etc.)

Restriction(s):

_________________________________________________________________

________________________________________________________________

Next appointment or evaluation date: _____________________________________________

The above employee is subsequently released to full duty, on

(Date), as

s/he is able to perform the essential job functions as recorded on the accompanying “Class

Specification” without restrictions.

Health Care Provider (Please Print Name)

Type of Practice

Address

Telephone Number

City, State, Zip Code

Signature of Health Care Provider

Date

Physician'S Release Return To Work Form "With" Or "Without" Restrictions