Workers' Compensation Return To Work Form - State Of Oklahoma
ADVERTISEMENT
1State of Oklahoma
Workers’ Compensation Return to Work Form
Completed form is to be returned to employer following each patient visit.
Employee’s Name: _______________________________________________________ Appt. Date: _________________
SSN: ______________________ Date of Injury: _____________ Employer: _____________________________________
Brief diagnosis of injury/illness: ________________________________________________________________________
RETURN TO WORK STATUS
Release: (check only one)
1.
Patient is unable to return to work.
2.
Full Duty Release: employee has reached maximum medical improvement (MMI) and is released from
active medical care.
3.
Full Duty Release without Temporary restrictions: employee is able to work full duty without restrictions, but is
not released from active medical care.
4.
Light Duty Release with Temporary Restrictions: employee has NOT reached (MMI) and can return to Light
Duty Work with the following temporary restrictions: (COMPLETE RESTRICTIONS SECTION)
5.
Will medication use prohibit driving or operation of heavy equipment? Yes
NO
Restrictions: (check all that apply and fully describe below)
No Restrictions
Temporary Restrictions
Permanent Restrictions
1.
Restricted lifting/carrying (maximum weight in pounds) ______ other _____ frequency _____
2.
Restricted pushing/pulling of _____ lbs.
3.
Restricted reaching: above chest _____ overhead _____ away from body _____ other _____
4.
Restricted to one-handed duty. No use of: right hand _____ left hand _____
5.
Restricted: walking
standing
sitting (describe)
partial wt bearing (describe)
6.
Wear splint at: all times
work
at night (describe)
7.
No more than
repetitive movements per
day or
hour of :
Hand Grasp L
R
Wrist L
R
Elbow Flexion L
R
Shoulder L
R
Foot L
R
Torso Flexion
8.
DO NOT: Operate Machinery
Crawl
Kneel
Squat
Drive any vehicle
Climb
Bend
Stoop
9.
Fully describe restrictions (i.e. duration, nature of limitation, etc.) add extra pages if needed:
_________________________________________________________________________________________
Patient requires follow up treatment on: Date: __________________________
_
Time:
__
_______________________
Medications: _______________________________________________________________________________________
Physician’s notes: ___________________________________________________________________________________
Physician’s Signature: _______________________________________________ Date: _________________________
Address: __________________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal