Fill and Sign the Oregon Work Form

Return form to:       RETURN-TO-WORK STATUS Worker’s name:       Claim number (if known):       Next scheduled appointment date:       Is the worker expected to materially improve from medical treatment or the passage of time? Yes No WORK STATUS (Select one option) OPTION 1 – Released to Regular Work Status from (date):       Released to the hours routinely worked and tasks routinely performed in the job held at the time of injury. OPTION 2 – Not Released to Work Status from (date):       to:       The worker is not capable of performing any work activities . OPTION 3 – Released to Modified Work Status from (date):       to:       Released to work, subject to the following work restrictions (note only those that are applicable): Total work hours:     hours/day Lift/carry/push/pull restrictions One- time ≤ 1/3 of work day 1/3-2/3 of workday ≥ 2/3 of work day Duration Lift:     pounds     pounds     pounds     pounds     hrs./day     hrs./one time Carry:     pounds     pounds     pounds     pounds     hrs./day     hrs./one time Push:     pounds     pounds     pounds     pounds     hrs./day     hrs./one time Pull:     pounds     pounds     pounds     pounds     hrs./day     hrs./one time Activity restrictions Stand:     hrs./da y     hrs./one time Twist:     hrs./day     hrs./one time Crawl:     hrs./day     hrs./one time Walk:     hrs./da y     hrs./one time Climb:     hrs./day     hrs./one time Crouch:     hrs./day     hrs./one time Sit:     hrs./da y     hrs./one time Bend:     hrs./day     hrs./one time Balance:     hrs./day     hrs./one time Drive:     hrs./da y     hrs./one time Above- shoulder- reach: Below- shoulder- reach: Kneel:     hrs./da y     hrs./one time     hrs./day     hrs./one time     hrs./day     hrs./one time Hand use restrictions Foot use restrictions Fine actions:     hrs./day L hand     hrs./day R hand Raise:     hrs./day L foot     hrs./day R foot Keyboarding:     hrs./day L hand     hrs./day R hand Push:     hrs./day L foot     hrs./day R foot Grasp:     hrs./day L hand     hrs./day R hand Notes / other restrictions:             Medical provider’s signature:       Date:       Print medical provider’s name:       Phone no.:       440-3245 (2/16/DCBS/WCD/WEB)