Wc-3/00 - Workers Compensation Return To Work Form
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1Workers Compensation Return to Work Form
Michigan Technological University
1400 Townsend Drive, Houghton MI 49931
Employee Name: _______________________________________________ and date of injury/illness: ______/______/______.
Examination/treatment date: ____/____/____.
Brief diagnosis of injury: (Indicate clinical manifestation of condition to what body part or surface).
Patient Has Been Advised of the Following Regarding Return to Work:
1.
_____
Return to work immediately with NO restrictions.
2.
_____
Medication has been prescribed. Please indicate any restrictions on the employee’s work activities as a result of
medication.
3.
_____
No return to work until (date) ____/____/____ (no work until this date and no medical restrictions after this date).
4.
_____
Return to work with temporary restrictions beginning (date) ____/____/____ and ending (date) ____/____/____.
Next scheduled examination/treatment (date) ____/____/____. Please indicate restrictions below:
Number of Consecutive Hours Patient Can Perform
Weight Handling Frequencies
Specified Activity During an 8-hour Work Period
Number of Hours
6-8
4-5
1-3
0
Number of Times Per
15 or
10-15
1-10
0
Hour
More
Sitting
Lifting & Carrying
Standing
a. Less than 10 pounds
Walking
b. 10-20 pounds
Pushing
c. 20-50 pounds
Pulling
d. 50-100 pounds
Climbing
Bending
Number of constructive hours patient can perform
the above weight handling frequencies during an 8-
Kneeling
hour work period?
Reaching
Grasping
Indicate any additional restrictions:
Attending Physician’s Signature
:
Print Name:
Address:
Employee:
Completed form to be returned to supervisor following each examination.
Supervisor: When received, route this form immediately to Occupational Safety & Health Services.
WC-3/00
Fax: (906)487-3048
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