Original Work Release Form
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1
2Form No. FRM-0098
Work Release Form
Attention:
Medical Provider
Modified work other than the patient's regular job may be available. To assist in restoring
the patient's regular work and pay, please complete the information below
Patient's Name_______________________________________________________
Date of Injury/Illness _______________________
No Duty from ______________ to _______________
Modified Duty from ______________ to _______________
Return to Full Duty on ___________
Modified Duty Limitations Physical Limitations
No prolonged standing ___________________________________________
No prolonged walking ____________________________________________
No prolonged sitting ______________________________________________
No knee bending, squatting, kneeling _______________________________
Limited or no use of ______________________________________________
Weight lifting restrictions __________________________________________
Keep affected area elevated _______________________________________
Keep dressing dry and clean _______________________________________
Use crutches/sling/splint ___________________________________________
Other _________________ ________________________________________
Page 1 of 2
Ardent Services, LLC
Form No:
FRM-0098
Restricted Duty Form
O-SS-FRM-0098
Revision:
0
Safety Manual - Appendix A – First Aid & Emergency Response
Doc No:
Program
Safety Manual Sect: B.8
Rel Date:
Nov 2002
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