Work Restriction Form

Work Restriction
Following a leave of absence when an employee is able and ready to return to work they must have their doctor fill out the attached Work Restriction Form and present it to their supervisor upon returning to work. Both the employee and the physician must sign the completed Work Restriction Form.

Free Sample Template

Format: Word PDF
# of Pages: 3
Printable: Yes

Work Restriction Template	Form 1366
Format: Word PDF Category: Employee, Schedule Type: Form

Work Restriction Form

Employee Name_______________________________________________________________

Address: _____________________________________________________________________

City: ________________________________ State: ___________ Zip Code: _______________

Employee Number: ____________________________________________________________

Employee has restrictions: ___Yes ___No

If yes, what is the estimated duration of the restrictions? _______________________________

Restrictions :

Movement & Posture: Please indicate the hours and minutes.

Example

Sit for __2 hours__ at a time for a total of ___8 hours_____ with a __10 min______ break of:

___X_____ standing ____X____ walking ________ sitting

Sit for ________ at a time for a total of ________ with a ________ break of:

________ standing ________ walking ________ sitting

Stand for ________ at a time for a total of ________ with a ________ break of:

________ standing ________ walking ________ sitting

Walk for ________ at a time for a total of ________ with a ________ break of:

________ standing ________ walking ________ sitting

Strength:

Weight in lbs.

0 – 10

11 -20

21 – 50

51 - 75

Lift / Carry below waist

Lift / Carry at waist / chest

Lift / Carry above shoulder

Push / Pull

Hand and Foot Movement:

Never

Occasional > 2.5 hrs.

Frequent 2.5 – 5 hrs.

Continuously > 5 hrs.

Simple Grasp

Power Grasp

Finger / Fine Manipulation

Foot Controls

Repetitive Hand Movements

Kneel

Bend

Squat

Climb

Psychological and Mental Demands:

Basic Work:

Yes

Follow verbal instructions

Follow written instructions

Maintain established work pace

Adhere to established work and safety procedures

Interaction with Others:

Work cooperatively with coworkers

Interaction with customers

Supervise others

Maintain composure in all circumstances

Respond correctly to direction and evaluation

Work independently with minimal supervision

Attention to Task and Details

Yes

Perform simple or repetitive tasks

Perform complex or varied tasks

Organize tasks and set priorities

Perform and or direct multiple tasks

Decision Making

Give training or instruction

Use basic problem solving techniques

Make independent decisions and judgments

Make decisions for group

Additional Comments:

______________________________________________________________________________

Health Care Provider Information:

Name: _______________________________________________________________________

Address: _____________________________________________________________________

City: ________________________________ State: ___________ Zip Code: _______________

Phone Number: _______________________________________________________________

Physician’s Signature: __________________________________________Date: ___/___/_____