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To: Health Care Provider Subject: Employee: ________________
From: Company Name SS#: ______________________________
We want to assist our employee and your patient to return to work as soon as possible and assist him/her in performing essential job functions at this institution. The information you provide on this form is vital and will be used for the following considerations:
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Allowing the employee to work without risk of further injury;
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Revision of a temporary assignment if necessary that meets the employee’s needs and the needs of this institution.
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Provision of any temporary reasonable accommodations to aid the employee in performing his/her duties.
The employee’s job description is attached for your consideration:
____ Regular Job Description ____ Temporary Assignment Job Description
If you have any questions regarding the information requested on this form, please contact:
_________________________________________________________________________
Name & Title of Hosting Department Supervisor Telephone Number
TO BE COMPLETED BY HEALTH CARE PROVIDER
Considering this employee’s job duties and health condition, this employee may perform work in the following manner:
| ____ Full Duty (no restrictions) |
Beginning:__________ |
| ____ Regular Job Description |
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| ____ Less than Full Duty (some restrictions) |
Beginning:__________ |
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___Temporary Assignment Job Description
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Additional Restrictions to Temporary Assignment Job Description should be noted on the Temporary Assignment Job Description.
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| ____ Off Work until Re-evaluated by Provider |
Beginning:__________ |
| Next Office Visit Scheduled: __________ |
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______________________________________ _______________________
Health Care Provider’s Signature Date
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