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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:
- 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 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
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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.
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.