Return To Work Restrictions Form
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2Return to Work Restrictions Form
Notes to physician
Bourgault Industries Ltd. wishes to ensure the prompt and safe rehabilitation and return to work of our team
members. We are committed to providing suitable and meaningful modified duties for team members unable
to perform their regular duties as a result of injury or illness. We welcome the support and interest of you, the
health care professional, in meeting our commitment and assisting us in this effort.
Mental Health: Avoidance of anxious situations is thought to increase the likelihood that one will avoid future
anxiety-inducing situations. For that reason Bourgault Industries focus is on determining work that facilitates
the employee remaining in the workplace. When time away from work is required for medical reasons it is most
helpful when this includes a clear treatment plan that will realistically return the employee back to work at a
functional level.
Name of Health Care Professional (please print): _________________________________________
Signature of Health Care Professional: _________________________________________________
I saw _______________________________________________ on _________________________.
(Print patient’s name)
(Date)
Date of injury or illness ______________________________
(Date)
This patient is medically able to work with limitations or restrictions as of ________________________
(Date)
Restrictions or limitations (see page 2 for details)
In my opinion, these restrictions or limitations may affect activity for:
days
______ weeks
Greater than ______ weeks
______
Date of next appointment is (indicate n/a if not applicable) ________________________.
(Date)
My opinion is based on the factors indicated below:
Information provided by the patient
My examination of the patient and my assessment of the finding and health information
Should you wish to discuss the Return to Work Restrictions Form, please contact Bourgault Human
Resources at 701-852-8800
Address: ________________________________________________ Telephone: ______________________
Note: a fee of $15.00 will be provided for completion of this form, please invoice to the attention of the Human
Resources Dept.
Please return with disabled Team Member or e-mail/fax to:
Bourgault Industries Ltd.
PO Box 1118, 3915 N. Broadway
Minot, ND 58702
Tel: (701) 852-8800 Fax: (701) 852-8844
E-mail:
Attention: Human Resources Department
Return to Work Restrictions form – F602501b M – r1 – bn- 10/02/13
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