WHAT YOU NEED TO KNOW:

You may need to give your employer a return to work form after your illness or injury. Ask your healthcare provider to fill out this form. Make copies of the form. Keep one copy and give another copy of the completed form to your employer.

Date of illness, injury, or procedure:

• May return to work with the following work restrictions:
  • Lifting and carrying:
    
    
  • Workday limits:
    
    
  • Activity:
    
    
  • Driving and machinery operation:
    
    
  • Avoid dirt and moisture:
    
    
  • Restrictions due to medications:
  
  
• May return to regular work activity with NO restrictions on:
  
  
• Follow-up visit information:

If your condition is (or may be) work-related: Tell your employer about your work-related illness or injury as soon as possible. Those that you should talk to may include your supervisor, human resources, and employee health. Ask your employer about any paperwork or follow-up visits that may be required after a work-related illness or injury.

Healthcare provider's signature:

Date signed:

Date of last medical evaluation (if different than above):

Medical healthcare provider's name and information (please print):

For more information:

• U.S. Department of Labor
  Frances Perkins Building
  Washington , DC20210
  Phone: 1- 866 - 487-2365
  Web Address: http://www.dol.gov
  

• Occupational Safety and Health Administration (OSHA), US Dept of Labor
  200 Constitution Ave, NW
  Washington , DC20210
  Phone: 1- 800 - 321-6742
  Web Address: http://www.osha.gov
  

CARE AGREEMENT:

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment.