Physician Release to Return to Work Form
To be completed by physician
Employee's Name
First Name
Last Name
Physician's Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
The employee is able to return to work and perform the essential duties of his/her job
The aforementioned employee has been released by the physicist mentioned above to return to the Full Duty (please select the date below) without any restrictions.
The above employee has been released by the above physician to return to work (please select the following date): WITH THE FOLLOWING RESTRICTIONS (please select the following date):
Date of returning to the work
-
Month
-
Day
Year
Date
Following restrictions until the date
-
Month
-
Day
Year
Date
Restrictions
Check applicable boxes
lbs
Lifting (Max weight in lbs)
Repetitive Lifting
Carrying
Pushing/pulling
Pinching/Gripping
Reaching over head
Repetitive Motion Restrictions
Limitations
Check applicable boxes
hours per day
Walking
Standing
Sitting
Crawling
Kneeling
Squatting
Climbing
These limitations/restrictions are
Permanent
Temporarily
Physician's Signature
Clear
Submit
Should be Empty: