Return To Work Form

ADVERTISEMENT

Return to Work Form
An important aspect of our company’s Return-to-Work program is returning an employee to work as soon as medically able after a
medical leave of absences. Please provide the following information so that we can best determine the physical limitations of the
employee, and if necessary, place the employee in a suitable temporary modified job.
Employer
Contact Person
Athelas Institute, Inc
Tisha Mathes, HRM
Employer Address
City
State
Zip Code
9104 Red Branch Road
Columbia
Maryland
21045
Employer Phone
(410) 964-1241
Employee’s Social Security Number
Name of employee
-
-
Employees Phone
Effective date of leave
Reason for Medical Leave
(
)
-
/
/
Job Title
Department
Please complete the following information and fax to 410-992-9989
Physician’s Evaluation
Worker is released to:
full duty without limitations
effective (date)
/
/
modified duty
from (date)
/
/
through (date)
/
/
specify limitations
modified hours
hours
from (date)
through (date)
1
2
3
4
5
6
7
8
Hours:
Other functional limitations or modifications necessary in worker’s employment:
Physician Signature
Date
/
/
Physician’s Phone Number
Physician Name
(
)
-
Physician’s Address
City
State
Zip Code

ADVERTISEMENT

11 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go