Physician'S Return-To-Work And Voucher Report - State Of California
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2Physician's Return-to-Work & Voucher Report
FOR INJURIES OCCURRING ON OR AFTER 1/1/13
The Employee is P&S from all conditions and the injury has caused permanent partial disability
Employee Last Name
Employee First Name
MI
Date of Injury
Claims Administrator
Claims Representative
Employer Name
Employer Street Address
Employer City
Zip Code
State
Claim No.
The Employee can return to regular work
The Employee can work with the following restrictions:
hours: 1-2 2-4 4-6 6-8 None
Lift/Carry Restrictions: May not lift/carry at a height of
Standing
hours per day.
more than
lbs. for more than
Walking
Describe in what ways the impaired activities are limited:
Sitting
Climbing
Forward Bending
Kneeling
Crawling
Twisting
Keyboarding
R/L/Bilat Hand(s) (circle): Grasping
R/L/Bilat Hand(s) (circle): Pushing/
Pulling
Other: _______________ (See below)
Regular
Modified
Alternative Work
If a Job Description has been provided, please complete:
Job Title:
Work Location:
Are the work capacities and activity restrictions compatible with the physical requirements
Yes
set forth in the provided job description?
No, explain below
Role of Doctor
Physician's Name
(PTP, QME, AME)
Date
Physician's Signature
DWC AD Form 10133.36 (SJDB) Eff: 1/1/14
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