Article Map
Preview - Work Release Form
Return to Work Release and Work Ability
Employee Name: __________________________________________
Return to Work
Return to work with no limitations on ________/________/__________
Return to work with limitations on _________/_________/__________ (note limitations below)
Employee’s Capabilities
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Occasio |
Freque |
Continuo |
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Lift/Carry |
all |
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No lifting |
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Push/Pull without resistance |
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> 40 lbs |
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Bend |
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Twist/turn |
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Kneel/squat |
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Sit |
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Stand/walk |
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Ladder/stair |
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climb |
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Hand, wrist, and shoulder activities |
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Avoid prolonged, repetitive, or forceful: |
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Gripping/grasping |
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Repetitive wrist |
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motion |
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Reaching |
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Above |
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shoulder |
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At shoulder |
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height |
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Below |
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shoulder |
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This treatment has been discussed with the employee.
Restrictions (circle) |
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Keyboarding / hrs |
0 |
1 - 2 |
3 – 4 |
5 – 6 |
7+ |
Writing / hrs |
0 |
1 - 2 |
3 – 4 |
5 – 6 |
7+ |
Change positions every:
As needed
Half hour
One hour
Two hours
Worksite stretches
Exercises
Other
Comments:
_________________________________________________ |
__________________________ |
Physician Signature |
Date |
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