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RETURN-TO-WORK FORM - Bellin Hospital 2026
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- Click ‘Get Form’ to open the RETURN-TO-WORK FORM in the editor.
- Begin by entering the Employee/Patient Name and Date of Injury at the top of the form. This information is crucial for identifying the individual involved.
- Fill in the Diagnosis and Company fields to provide context regarding the patient's condition and employment.
- Select the appropriate DEGREE of work capability based on lifting requirements. Choose from options like No lifting, Sedentary Work, Light Work, etc., ensuring you accurately reflect the patient’s abilities.
- Complete the HAND SPECIFIC section by indicating any restrictions related to hand usage, such as avoiding extreme temperatures or requiring a splint.
- In LIMITATIONS, specify how many hours per day the patient can stand, walk, sit, and drive. Mark any repetitive movements they can perform with their hands or feet.
- Finally, ensure that both Physician’s Signature and Patient’s Signature are completed along with dates before submitting the form.
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