Release Form To Return To Work
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1Return form to:
RELEASE TO RETURN TO WORK
Name of worker
Claim number
Please fill out this form and return it to us at the address indicated above.
1. Is the worker medically stationary?
Yes
No
If yes, date:
(Provide closing information and complete Form 827.)
If no, estimated medically stationary date:
Are there permanent restrictions?
Yes
No
Unknown
Next scheduled appointment date:
2. Worker is released to:
full duty without limitations
Date:
(Do not complete lines 3 through 11. Sign below.)
modified duty
from (date):
through (date):
(specify limitations below)
modified hours
specify hours:
from (date):
through (date):
not released to work
Est. RTW date:
If modified releas e, provide date of anticipat ed regul ar releas e:
Hours: No limitations
1
2
3
4
5
6
7
8
Other (specify)
3. In a/an
8
10
12
other
-hour work da y ,
worker can stand/walk a total of
4. At one time, worker can stand/walk
5. In a/an
8
10
12
other
-hour workd a y,
worker can sit a total of
6. At one time, worker can sit
7. The worker is released to return to work in the following range for lifting, carrying, pushing/pulling:
Pounds
<10
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100 >100
Occasionally
Frequently
8. Worker can use hands for repetitive:
Right
Left
a. Fine manipulation
Yes
No
Yes
No
Dominant hand
b. Pushing and pulling
Yes
No
Yes
No
Right
Left
c. Simple grasping
Yes
No
Yes
No
d. Keyboarding
Yes
No
Yes
No
9. Worker can use feet for repetitive raising and pushing (as in operating foot controls):
Yes
No
10. Worker is able to:
Continuous
Freque ntly
O ccasionally
Inte rmitte ntly
Not at all
67-100% of the day
34-66% of the day
6-33% of the day
1-5% of the day
--------------------------
-----------------------------
--------------------------
------------------------
a. Stoop/bend -------------------
b. Crouch -------------------------
---------------------------
-----------------------------
--------------------------
------------------------
c. Crawl ---------------------------
---------------------------
-----------------------------
--------------------------
------------------------
d. Kneel ---------------------------
---------------------------
-----------------------------
--------------------------
------------------------
e. Twist ---------------------------
---------------------------
-----------------------------
--------------------------
------------------------
f. Climb ---------------------------
---------------------------
-----------------------------
--------------------------
------------------------
g. Balance ------------------------
---------------------------
-----------------------------
--------------------------
------------------------
h. Reach --------------------------
---------------------------
-----------------------------
--------------------------
------------------------
i. Push/pull ----------------------
---------------------------
-----------------------------
--------------------------
------------------------
11. Other functional limitations or modifications necessary in worker’s employment:
Additional comments may be written on back of form.
Printed name
Date
Signature of medical service provider
440-3245 (10/05/DCBS/WCD/WEB)
See OAR 436-010-0210 regarding who may provide medical services and authorize time loss.
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