Return To Work Program Evaluation Template
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1SAMPLE: Return to Work Program Evaluation Template
_______________________________________________________________________
Baseline Period: From__________________ To ________________________
Evaluation Period: From_________________ To_________________________
INDICATOR
BASELINE
EVALUATION PERIOD
DIFFERENCE +/-
LOST TIME INJURIES:
# OF LOST TIME
INJURIES
AVERAGE # OF DAYS
LOST PER LOST TIME
INJURY
ACTUAL # OF LOST
DAYS FOR ALL LOST
TIME INJURIES
AVERAGE COST PER
LOST TIME INJURY
TOTAL COSTS FOR
ALL LOST TIME
INJURIES
NUMBER OF LOST
TIME INJURIES BY
TYPE
BACK/NECK
HIP/ANKLE/KNEE/
FOOT
SHOULDER
HAND/WRIST/
ELBOW
RETURN TO WORK:
AVERAGE # OF DAYS
FROM DATE OF
INJURY TO DATE OF
RTW PLAN
AVERAGE # OF DAYS
FROM DATE OF
INJURY TO START OF
RTW PLAN
AVERAGE TIME TO
RTW BY OUTCOME
TYPE (E.G. PRE-
INJURY, ALTERNATE,
TEMPORARY)
% OF LOST TIME
INJURIES THAT
RETURNED TO PRE-
INJURY JOB
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Parent category: Business