Appendix R


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:
  • Allowing the employee to work without risk of further injury;
  • Revision of a temporary assignment if necessary that meets the employee’s needs and the needs of this institution.
  • 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

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    
____  Less than Full Duty (some restrictions)  Beginning:__________
                    ___Temporary Assignment Job Description
Additional Restrictions to Temporary Assignment Job Description should be noted on the Temporary Assignment Job Description.
____  Off Work until Re-evaluated by Provider   Beginning:__________
                    Next Office Visit Scheduled: __________  
______________________________________                   _______________________
Health Care Provider’s Signature                                       Date
Contact UsCommonwealth PortalContact the Web Team | Privacy PolicyDisclaimer
Copyright ©  Commonwealth of Pennsylvania