Return To Work Authorisation Form Template for United States

The Return to Work Authorization Form is a crucial document used when employees need to return to work following medical leave, injury, or extended absence. This form is designed to comply with United States federal and state employment laws, including HIPAA, ADA, FMLA, and state workers' compensation requirements. It serves multiple purposes: documenting medical clearance for return to work, specifying any work restrictions or required accommodations, ensuring workplace safety compliance, and protecting both employer and employee interests. The form typically requires input from healthcare providers, human resources professionals, and supervisors, creating a clear record of the terms and conditions under which an employee may safely resume work duties. It's particularly important in cases involving workers' compensation claims, disability accommodations, or extended medical leaves.

1. Employee Information: Basic details including name, employee ID, department, and position

2. Leave Information: Details about the leave period, including start date and reason for leave

3. Medical Provider Authorization: Healthcare provider's certification of fitness to return to work

4. Return to Work Date: Specific date the employee is cleared to resume work

5. Work Capacity Statement: Clear indication of whether return is full duty or with restrictions

6. Required Workplace Modifications: Any necessary modifications or restrictions specified by healthcare provider

7. Authorization Signatures: Signature blocks for employee, healthcare provider, and employer representative