EMPLOYEE RETURN TO WORK PLAN

NAME OF INJURED WORKER	TITLE / ROLE
SUPERVISOR NAME	DEPARTMENT / AREA

DATE OF RETURN	TIME
YOU HAVE BEEN SCHEDULED TO RETURN TO WORK ON:

YOU ARE WORKING WITH THE FOLLOWING RESTRICTIONS AS PER YOUR PHYSICIAN:
THE FOLLOWING REVIEW AND BRIEFING HAS OCCURRED
The physician’s restrictions have been identified and clarified.
The supervisor is able to understand the restrictions and provide accommodated work.
A communication pathway to get support has been provided to the injured worker.
A review of pertinent safety policies / practices has occurred.
A review of pertinent human resources policies, including reporting off work, clocking in / out, and similar procedures, has been made.
The Job Demand Analysis has been reviewed in conjunction with the restrictions indicated by the physician. Duties have been assigned as noted below.
Requirements of the injured worker to work within restrictions have been clarified.
Requirements of the supervisor to only assign work within restrictions have been clarified.
Requirement of the injured worker to immediately go to their physician’s office (or emergency room) if they are leaving work because they feel that they cannot perform the work or because they feel that they may have been re-injured.

ASSIGNED TASKS attach separate pages as necessary

WK. NO.	ASSIGNED DUTIES	EMPLOYEE FEEDBACK	SUPERVISOR FEEDBACK	Continue Modified Duty? YES / NO	Full Return to Work? YES / NO
1
2
3
4
5
6
7
8

AGREEMENT

I, the undersigned injured worker, agree to participate in the transitional work plan described herein. I agree to perform my work carefully and to work within my restrictions. I also agree to ask for help when work exceeds my abilities, to notify my supervisor if there are duties assigned that exceed by abilities, and to notify my supervisor if I need assistance.

NAME	SIGNATURE	DATE
EMPLOYEE	CC: Workers’ Compensation Coordinator Supervisor file Employee file
SUPERVISOR

DISCLAIMER Any articles, templates, or information provided by Smartsheet on the website are for reference only. While we strive to keep the information up to date and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability, or availability with respect to the website or the information, articles, templates, or related graphics contained on the website. Any reliance you place on such information is therefore strictly at your own risk.