Return To Work Form
An employer can require this work status form from an injured worker who has been off work or on transitional duties. It includes space for a doctor to sign.
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Description
Return to Work Form
Fields: Employer, name, ID #, injury date, exam, next exam, physical duties, transitional duty, full duty, physician certifies that patient can work (full duty, transitional duty, unable to work), physician certification (name, signature, facility address, facility phone, date).
