Physician Release to Return to Work Form
To be completed by physician
Employee's Name
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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
Date of returning to the work
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Following restrictions until the date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Restrictions
Rows
Check applicable boxes
lbs
Lifting (Max weight in lbs)
1
Repetitive Lifting
2
Carrying
3
Pushing/pulling
4
Pinching/Gripping
5
Reaching over head
6
Repetitive Motion Restrictions
7
Limitations
Rows
Check applicable boxes
hours per day
Walking
8
Standing
9
Sitting
10
Crawling
11
Kneeling
12
Squatting
13
Climbing
14
Physician's Name
First Name
Last Name
Physician's Signature
Submit
Should be Empty: