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
1
Rows
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
Submit
Should be Empty: