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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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