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Return To Work Instructions

You may need to give your employer a return to work form after your illness or injury. Ask your healthcare provider to fill out this form. Make copies of the form. Keep one copy and give another copy of the completed form to your employer.

Date of illness, injury, or procedure:

Do not return to work until your healthcare provider says it is okay.
  • May return to work with the following work restrictions:

    • Lifting and carrying:

    • Workday limits:

    • Activity:

    • Driving and machinery operation:

    • Avoid dirt and moisture:

    • Restrictions due to medications:

  • 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.

Healthcare provider's signature:

Date signed:

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

Medical healthcare provider's name and information (please print):

For more information:

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

Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. 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.

© 2015 Truven Health Analytics Inc. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or Truven Health Analytics.

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