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Return to Work Form

Return to Work Form

Use a printable return to work form pdf 0 template to make your document workflow more streamlined.

Day, for how many hours can this employee sit, stand, and/or walk in combination? 2 4 6 8 10 12 14 16 Greater than 16 3a. Other Capabilities: (please check appropriate boxes) Never Occasionally Frequently Continuously Lift 0-10 lbs 11-20 lbs 21-50 lbs 50-100 lbs Carry 0-10 lbs 11-20 lbs 21-50 lbs 50-100 lbs Bend Squat Climb Run Reach above shoulder level Operate a motor vehicle 3b. Upper Extremities: Which hand is dominant? Right Left Can this employee perform repetitive actions such...
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