Return To Work Instructions
GENERAL INFORMATION:
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 on ____ 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: ____
- __ Other special instructions: ____
- __ Lifting and carrying: (Include any weight limits) ____
- __ 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: http://www.dol.gov
- Occupational Safety and Health Administration (OSHA), US Dept of Labor
200 Constitution Ave
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. 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.
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