Return To Work Information

Return to Work Information

SECTION A:

T o be completed by the employer

Initial form

Follow-up

Social Insurance No.

Claim Number

Employee No.

(if available)

Worker’s Last Name

First Name

Home Telephone (

)

Home Address

Postal Code

Date of Accident / Onset of Illness

Area of Injury (if applicable)

Job at time of Accident / Illness

Physical Demands Analysis enclosed

Yes

No

Department / Division

Supervisor

Telephone

Work Address

Work Telephone

SECTION B: T o be completed by the treating health professional and returned to the worker

Nature of problem

medical illness

injury (please indicate)

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Estimated recovery time

Is complete recovery expected

Yes

No

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Please specify further treatment required, if any

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Ability to return to work (check one):

Able to return to work immediately without restrictions

Able to return to modified duties. Modified duties are recommended for

days or

weeks

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Unable to participate in any work, including modified duties for

days or

weeks

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If modified duties are required, please check any specific medical restrictions necessary:

LIFTING (floor to knuckle)

No loads > 20 kg

No loads > 10 kg

Occasional lifting only

LIFTING (knuckle to chest)

No loads > 20 kg

No loads > 10 kg

Occasional lifting only

LIFTING (above chest)

No loads > 20 kg

No loads > 10 kg

Occasional lifting only

CARRYING

No loads > 20 kg

No loads > 10 kg

Occasional carrying only

PUSHING / PULLING

No heavy pushing / pulling

Occasional pushing / pulling only

Avoid pushing / pulling

HAND FUNCTION

Avoid repetitive hand motion

No strong gripping

Avoid gripping

REACHING

No prolonged overhead reaching

No overhead reaching

Avoid any reaching

SITTING

No prolonged sitting

STANDING

No prolonged standing

Avoid standing

WALKING

No prolonged walking

Avoid uneven ground

Avoid walking

CLIMBING (stairs / ladders)

Occasional climbing only

No ladder climbing

BENDING

No prolonged bending

Occasional bending only

Avoid bending

CROUCHING /KNEELING

No prolonged crouching / kneeling

Occasional crouching / kneeling only

Avoid crouching / kneeling

Are there any contraindications to the testing process if the City’s disability management staff recommend this employee for

functional abilities testing

Yes

No

Comments / Specific limitations:

Please describe any additional related medical restrictions pertaining to – effects of medication,

driving vehicles or operating equipment, physical exertion, vibration, work environment, work hours.

Health professional’s name and title (please print)

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Address

Postal Code

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Telephone (

)

Signature

Date

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Examination date

Next appointment date

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SECTION C: W orker Consent (to be completed by worker):

I authorize the health professional involved with my treatment to provide to me, my employer, and the Workplace Safety and Insurance Board

(if applicable) this completed form containing information about any limitations / restrictions affecting my ability to return to work.

Signature

Date

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80000 7852 (R10/99)