• Employee Absence Return to Work Form

• Employee Information

• Name
  First Name Last Name
• Personal ID#
• Phone Number
   - Area Code Phone Number
• Department
• Home Address
  Street Address

  Street Address Line 2

  City State / Province

  Postal / Zip Code

• HEALTHCARE PROVIDER INFORMATION

• Name of Healthcare Provider
  First Name Last Name
• Healthcare Provider Phone
   - Area Code Phone Number
• Name of Healthcare Practise
• Date of Examination*
   / Month  / Day Year

  Date
• Patient Condition
  Patient may return to work with no limitations or restrictions from: Patient may return to work on                                                 with the below mentioned restrictions & limitations

• 	Limits & Restrictions
  Duration of activity per day
  Lifting Limitations & restrictions
  Duration of standing activity
  Walking duration & restrictions
  Seated activity & restrictions
  Activities to be specifically avoided
  Others

• Signature
  Clear
• Submit
• Should be Empty: