Appendix R

RETURN-TO-WORK PROGRAM
PROVIDER FORM

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
 
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    
   
____  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
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