Work Comp Medical Form - City Of Watertown Page 2
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1
2ATTENDING PHYSICIAN’S
RETURN TO WORK RECOMMENDATION RECORD
Patient Name (Last)
(First)
(Middle)
Date of Injury/Illness
TO BE COMPLETED BY ATTENDING PHYSICIAN – PLEASE CHECK
Diagnosis and brief explanation of condition:
I saw and treated this patient on _______________ and based on the above description of the patient’s current medical problem:
Date
1.
Recommend his/her return to work with no limitations on ___________________.
Date
2.
He/she may return to work on ___________________ with the following limitations:
Date
CHECK ONLY AS RELATES TO ABOVE CONDITION
SEDENTARY WORK: Lifting 10 pounds maximum and
1. In an 8 hour work day patient may:
occasionally lifting and/or carrying such articles as dockets,
a. Stand/walk
4-6 Hours
ledgers, and small tools. Although a sedentary job is defined as
None
one which involves sitting, a certain amount of walking and
1-4 Hours
6-8 Hours
standing is often necessary in carrying out job duties. Jobs are
sedentary if walking and standing are required only occasionally
b. Sit
and other sedentary criteria are met.
3-5 Hours
5-8 Hours
1-3 Hours
LIGHT WORK: Lifting 20 pounds maximum with frequent
c. Drive
lifting and/or carrying of objects weighing up to 10 pounds. Even
5-8 Hours
1-3 Hours
3-5 Hours
though the weight lifted may be only a negligible amount, a job is
in this category when it requires walking or standing to a
2. Patient may use hand(s) for repetitive:
significant degree or when it involves sitting most of the time with
Single grasping
Pushing & Pulling
a degree of pushing and pulling of arm and/or leg controls.
Fine manipulation
LIGHT MEDIUM WORK: Lifting 30 pounds maximum with
3. Patient may use foot/feet for repetitive movement as in
frequent lifting and/or carry of objects weighing up to 20 pounds.
operating foot controls:
MEDIUM WORK: Lifting 50 pounds maximum with frequent
Yes
No
lifting and/or carry of objects weighing up to 25 pounds.
4. Patient may:
Not at all
Occasionally
Frequently
LIGHT HEAVY WORK: Lifting 75 pounds maximum with
a. Bend
frequent lifting and/or carry of objects weighing up to 40 pounds.
b. Twist
HEAVY WORK: Lifting 100 pounds maximum with frequent
c. Squat
lifting and/or carry of objects weighing up to 50 pounds.
d. Climb
e. Reach
.
DRY WORK: Work that would avoid moisture on injured area
OTHER INSTRUCTIONS AND/OR LIMITATIONS INCLUDING PRESCRIBED MEDICATIONS:
3.
These restrictions are in effect until _________________ or until patient is reevaluated on ______________.
Date
Date
4.
He/she is totally incapacitated at this time. The patient will be reevaluated on ______________.
Date
None
P Other Physician________________
5.
Consultant________________
Referred to:
Return Here
Name
Name
Date:
Physician’s Signature:
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize the physician or practitioner identified on this form to release and disclose to the City of Watertown such health
records and information concerning my medical condition as is necessary to support my request for absence from work and/or any
additional benefits my employer may provide.
Patient’s Signature:
Date:
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