Return To Work Form printable pdf download

RETURN TO WORK FORM

900 S. Crouse Avenue, 005 Steele Hall - 443-5367

119 Euclid Avenu Rm 107 - 443-5106

Today's Date:________________________________

Name of Employee: _______________________________

Job Title: ___________________________________

Department: _____________________________________

Last Day Worked: ____________________________

SUID#: _________________________________________

Department Job Analysis: Brief description of job tasks to be completed by supervisor:

Chemical, Tools, Equipment, Machines Used:

Physical Demands: Based on percentage of time required during the day, please note frequency as follows:

Constant (up to 100%)

Occasional (10% to 33%)

Never (0%)

Frequent (34% to 67%)

Rare (Less than 10%)

Standing

Kneeling

Handling/Fingering

Walking

Crouching

Reaching Forward

Sitting

Crawling

Concentration

Pushing

Twisting

Work/Deadline Pressures

Balancing

Climbing Stairs

Typing/Keying

Stooping

Reaching Overhead

Lifting and Carrying: Indicate the maximum amount

10 lbs

20 lbs

50 lbs

75 lbs

100 lbs

of weight the employee is expected to handle by

placing an X in the appropriate box.

Type of Leave:

NYS Disability or Workers Compensation – Contact Risk Management at 443-4011 (Fax: 443-1154)

Salary Continuation – Contact Dana Butler, Office of Equal Opportunity, Inclusion and Resolution Services at

(Fax: 443-5021)

Supervisor Name:_______________________

Contact Number:_________________________

Signature:_____________________________________________________

Date:________________________

Physician’s Assessment:

I have reviewed the above employee’s job requirements and my patient is:

Approved to return to work on:________________________(date)

Approved to return to work with modifications as follows: ___________________________________

______________________________________________________________________________________

Duration of modifications: ________________________________________________________________

Not approved to return to work until:_______________(targeted return to work date)

Physician’s Signature______________________________________ Date:_____________________

NOTE: The physician’s office must fax this form

to the appropriate department as noted above.

EO-142

Created 04/08

Revised 06/16

Return To Work Form

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