Employees Return To Work Form
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1EMPLOYEE'S RETURN TO
Human Resources
WORK FORM
1016 University Circle
Must be completed legibly by physician
Ogden, UT 84408-1016
801-626-6032 Fax: 801-626-6925
Patient's Name: __________________________________________________Date of Onset: _____________________
Date(s) of Treatment:
History:
Name(s) of other physician(s) or medical providers who have served on case:
Diagnosis:
Treatment (Proposed or completed):
Medication(s):
Prognosis:
First day off work:
Estimated return to work date:
Actual Return to Work without restrictions:
Return to work with reduced schedule:
Number of hours per day:
Number of days per week:
Beginning:
Ending:
Return to work with the following restrictions:
Beginning:
Ending:
Lifting (weight)
0-10 lbs.
11-25 lbs.
26-40 lbs.
41-50 lbs.
over 50 lbs.
Lifting
From Floor
25%
50%
75%
100%
From waist level
25%
50%
75%
100%
Over the shoulder/head
25%
50%
75%
100%
Pushing/pulling (weight)
0-10 lbs.
11-25 lbs.
26-40 lbs.
41-50 lbs.
over 50 lbs.
Pushing/pulling frequency
25%
50%
75%
100%
Standing
25%
50%
75%
100%
Sitting
25%
50%
75%
100%
Walking
25%
50%
75%
100%
Climbing
25%
50%
75%
100%
Bending
18”from body
25%
50%
75%
100%
From shoulder level
25%
50%
75%
100%
Over the head
25%
50%
75%
100%
Kneeling/Squatting
25%
50%
75%
100%
No operating moving machinery
No Driving
Additional instruction:
Date of next office visit:
Physicians Name:
City, State, Zip:
Telephone Number:
Fax Number:
Physician’s Signature:
Date:
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Parent category: Business