SUPERVISOR’S REPORT

OF RETURN TO WORK FORM

INSTRUCTIONS: The supervisor shall fill out this form and then submit it to the Worker's Compensation Coordinator. Attach the Employee Return to Work Plan and submit it in addition to this form.

TO: WORKERS’ COMPENSATION COORDINATOR
FROM: SUPERVISOR NAME	DEPARTMENT / AREA

EMPLOYEE NAME	DATE OF RETURN
The following employee has returned to work:

THE EMPLOYEE IS: check all that apply
Performing their full duties with no restrictions.
Performing their duties with restrictions.
Has returned in a Transitional Work effort; and / or alternative duty has been assigned with restrictions.
Working their full schedule.
Working a partial day:	NO. OF HOURS PER DAY	START TIME	END TIME

COMMENTS:

NAME	SIGNATURE	DATE
INJURED WORKER
SUPERVISOR

*** RETURN COMPLETED FORM TO WORKERS’ COMPENSATION COORDINATOR ASAP ***

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.