Return To Work Instructions

Date of illness, injury, or procedure:

(Instructions for medical caregivers: Check all of the items below that apply. Fill in blanks as necessary.)
  • Do not return to work until you are re-checked by a medical caregiver and given permission to do so.

  • May return to work with the following work restrictions:

    • Lifting and carrying: (Include any weight limits)

    • Workday limits: (Include special instructions on length of workday, minimum amount of breaks, and limits on working outside)

    • Activity: (Include time limits on standing, sitting, or bending):

    • Driving and machinery operation:

    • Avoid dirt and moisture: Do not perform any activity that will expose the wound, incision, or injury area to dirt or moisture until

    • Restrictions due to medications: The following restrictions are required while you are on certain prescribed medication:

  • May return to regular work activity with NO restrictions on:

  • Follow-up visit information:

If your condition is (or may be) work-related: Tell your employer about your work-related illness or injury as soon as possible. Those that you should talk to may include your supervisor, human resources, and employee health. Ask your employer about any paperwork or follow-up visits that may be required after a work-related illness or injury.

Medical caregiver's signature:

Date signed:

Date of last medical evaluation (if different than above):

Medical caregiver's name and information (please print):

For more information:

Contact the following organizations if you have questions about your rights in the workplace after an illness or injury:

  • U.S. Department of Labor
    Frances Perkins Building
    Washington , DC 20210
    Phone: 1- 866 - 487-2365
    Web Address:
  • Occupational Safety and Health Administration (OSHA), US Dept of Labor
    200 Constitution Ave
    Washington , DC 20210
    Phone: 1- 800 - 321-6742
    Web Address:

Care Agreement

You have the right to help plan your care. To help with this plan, you must learn about your health condition and how it may be treated. You can then discuss treatment options with your caregivers. Work with them to decide what care may be used to treat you. As a patient, you always have the right to refuse treatment or to not follow medical advice. Doing so may increase your risk of continued or worsening health problems.The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

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