Return To Work Restrictions Form Template for United States

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Key Requirements PROMPT example:

Return To Work Restrictions Form

"I need a Return To Work Restrictions Form for an employee returning from knee surgery who will need modified duties in our warehouse facility, with specific lifting restrictions and a gradual return schedule starting March 15, 2025."

Document background

The Return To Work Restrictions Form is essential documentation required when employees resume work following medical absence. This form, designed to comply with U.S. federal and state regulations, provides crucial information about an employee's work capabilities, necessary accommodations, and duration of restrictions. It helps organizations maintain compliance with ADA, FMLA, and workers' compensation requirements while ensuring employee safety and appropriate job modifications. The form is particularly important in documenting medical provider authorizations and specific work limitations to protect both employer and employee interests.

Suggested Sections

1. Employee Information: Basic identifying information about the employee including name, employee ID, department, and position

2. Medical Provider Information: Details of the healthcare provider authorizing return to work, including name, contact information, and credentials

3. Return Date and Status: Specific date employee is cleared to return and whether return is full or modified duty

4. Work Restrictions: Detailed list of specific work limitations and accommodations required, including physical limitations and environmental restrictions

5. Duration of Restrictions: Time period for which restrictions apply and expected date of full duty return if applicable

Optional Sections

1. Modified Duty Description: Detailed description of temporary modified duties and responsibilities when employee requires temporary job modification

2. Follow-up Appointments: Schedule and requirements for future medical evaluations and follow-up appointments

3. Gradual Return Schedule: Detailed plan for phased return to full duties including timeline and progression of responsibilities

Suggested Schedules

1. Physical Capacity Form: Detailed medical provider assessment of physical capabilities and limitations

2. Job Description: Detailed description of employee's regular job duties and physical requirements

3. Modified Duty Plan: Specific plan outlining modified work arrangements including tasks, schedules, and duration

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Manufacturing
Healthcare
Construction
Office/Corporate
Retail
Transportation

Relevant Teams

Human Resources
Occupational Health
Safety & Risk Management
Legal
Operations
Benefits Administration

Relevant Roles

HR Manager
Occupational Health Nurse
Safety Manager
Department Supervisor
Benefits Coordinator
Risk Manager

Find the exact document you need

Medical Clearance To Return To Work Letter

A U.S.-compliant healthcare provider's document certifying an employee's fitness to return to work following medical leave.

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Let's create your Return To Work Restrictions Form

Authors

Alex Denne

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