PHYSICIAN RETURN-TO-WORK SAMPLE LETTER 

Re: (Employee Name) 

(Date/Type of Injury) 

Dear Dr. (Name), 

(Company name)'s Return-to-Work Program provides assistance to our injured employees in accomplishing as expeditious and productive a return-to-work as possible. Everyone benefits when an injured employee returns to work. The employee's self-esteem, earning potential and co-worker relationships are maintained. And we retain a valuable employee. 

You play an important role in this effort. We need your help in defining (employee name)'s current physical capabilities so that we may either return him/her to regular duty or identify appropriate transitional duty that will be both rewarding and therapeutic for him/her. I am enclosing an Employee Job Description form so that you will have a better picture of the employee's regular job duties. 

Please fax the following information regarding (employee name)'s current physical status to us at (fax number): 

         List and describe any physical restrictions/limitations based on the enclosed job description.

         List and describe activities the employee can and should be performing to heighten recovery.

         Describe current work status: (Maximum medical improvement, still improving, etc.)

         Describe any visual or hearing limitations that may affect performance.

         Describe any medications the employee is taking that may affect performance.

         Describe any pre-existing conditions that may have contributed to or exacerbated the injury. (For Second Injury Fund recovery purposes) 

Based upon (employee name)'s job description, at this time do you release him/her to: 

____ Full Duty 

____ Transitional Duty as outlined 

____ No work activities 

If the employee is currently restricted from all work activities, when do you project that he/she will be capable of engaging in any work activities? 

If necessary, (company name) will consider accommodations to help the employee perform essential job functions. If transitional duty is appropriate, I will be contacting you for your input and approval. Should you have any questions, please contact me at (phone number). Thank you for your help. 

Sincerely,

(Workers' Comp Coordinator) 

TRANSITIONAL DUTY OFFER

Employee Name ________________________________________________________________ 

Transitional Duty Supervisor(s) ____________________________________________________ 

Start Date______________________________ End Date______________________________ 

Salary______________________________ Hours/day___________ Hours/week___________ 

Transitional Duty Purpose and Objectives 

Description of Duties 

Transitional Duty Goals 

Expected Results 

Physical Requirements of Job 

(It is not necessary to list these charts in their entirety, pull out the sections that are relevant). 

____ Sedentary Work: Lifting 10 pounds maximum. Occasionally carry small objects. Occasional walking.

____ Light Work: Lifting 20 pounds maximum. Frequently lift/carry up to10 pounds. Frequent walking.

____ Medium Work: Lift 50 pounds maximum. Frequently lift/carry up to 25 pounds Unrestricted walking and standing.

____ Heavy Work: Lift up to 100 pounds maximum. Frequently lift/carry 50 pounds Unrestricted walking and standing.

____ Very Heavy: Lift in excess of 100 pounds. Frequently lift/carry 50 pounds. Unrestricted walking and standing. 

Description of required restrictions 

Description of safety equipment to be used 

Description of any accommodation to be made 

Monitoring Dates 

I have read the above transitional duty offer, which has been approved by my physician, and accept it. 

______________________________________________________________________________

Employee Signature Date 

______________________________________________________________________________

Employer Signature Date 

______________________________________________________________________________

Physician Signature Date 

Reprinted with permission. © CCH