Return to Work Arrangements Template

• Employee name:

• Incident #

• Conducted on

  Date

Employee Details

• Name of worker

• Pre-injury job title

• Pre-injury work location

• Pre-injury hours per week

Treating Medical Practitioner Details

• Name:

• Address:

• Phone number:

Medical restrictions

• Current capacity

  Fit for alternate duties

  Fit for modified duties

  Unfit

• List the employees current medical restrictions

• The above medical restrictions were listed on the certificate of capacity dated:

  Date

Return to work arrangements

• Describe the specific duties and tasks required. Include any physical requirements.

• Workplace supports, aids and modifications to be provided

• Specific tasks to be avoided

  Select heavy lifting bending twisting kneeling reaching shovelling driving mowing digging chipping using chainsaw using wacker plate using concrete cutter using crow bar using pick using rake / raking

  • heavy lifting
  • bending
  • twisting
  • kneeling
  • reaching
  • shovelling
  • driving
  • mowing
  • digging
  • chipping
  • using chainsaw
  • using wacker plate
  • using concrete cutter
  • using crow bar
  • using pick
  • using rake / raking

• Other tasks or duties to be avoided

Start date

• This plan starts on:

  Date

• This plan finishes on:

  Date

• Note: the duties contained within this plan are temporary in nature. The progression of the employee in these duties will be regularly reviewed by the Return to Work Coordinator. Where an employee is not progressing within the set duties, or where the duties are deemed no longer suitable, safe or sustainable - a decision may be made to withdraw these duties.

Work times

• This plan goes for the following number of weeks:

  1 Week

  2 Weeks

  3 Weeks

  4 Weeks

Week 1

• Is the start and finish time the same each day?

  Yes

  No

• Days of the week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Start time each day:

  Select 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am 8:30 am 9:00 am 9:30 am

  • 6:00 am
  • 6:30 am
  • 7:00 am
  • 7:30 am
  • 8:00 am
  • 8:30 am
  • 9:00 am
  • 9:30 am

• Finish time each day:

  Select 3:00 pm 3:30 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm

  • 3:00 pm
  • 3:30 pm
  • 4:00 pm
  • 4:15 pm
  • 4:30 pm
  • 5:00 pm
  • 5:15 pm
  • 5:30 pm

• Monday

• Start

  Date

• Finish

  Date

• Tuesday

• Start

  Date

• Finish

  Date

• Wednesday

• Start

  Date

• Finish

  Date

• Thursday

• Start

  Date

• Finish

  Date

• Friday

• Start

  Date

• Finish

  Date

• Saturday

• Start

  Date

• Finish

  Date

• Sunday

• Start

  Date

• Finish

  Date

Week 1

• Is the start and finish time the same each day?

  Yes

  No

• Days of the week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Start time each day:

  Select 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am 8:30 am 9:00 am 9:30 am

  • 6:00 am
  • 6:30 am
  • 7:00 am
  • 7:30 am
  • 8:00 am
  • 8:30 am
  • 9:00 am
  • 9:30 am

• Finish time each day:

  Select 3:00 pm 3:30 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm

  • 3:00 pm
  • 3:30 pm
  • 4:00 pm
  • 4:15 pm
  • 4:30 pm
  • 5:00 pm
  • 5:15 pm
  • 5:30 pm

• Monday

• Start

  Date

• Finish

  Date

• Tuesday

• Start

  Date

• Finish

  Date

• Wednesday

• Start

  Date

• Finish

  Date

• Thursday

• Start

  Date

• Finish

  Date

• Friday

• Start

  Date

• Finish

  Date

• Saturday

• Start

  Date

• Finish

  Date

• Sunday

• Start

  Date

• Finish

  Date

Week 2

• Is the start and finish time the same each day?

  Yes

  No

• Days of the week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Start time each day:

  Select 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am 8:30 am 9:00 am 9:30 am

  • 6:00 am
  • 6:30 am
  • 7:00 am
  • 7:30 am
  • 8:00 am
  • 8:30 am
  • 9:00 am
  • 9:30 am

• Finish time each day:

  Select 3:00 pm 3:30 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm

  • 3:00 pm
  • 3:30 pm
  • 4:00 pm
  • 4:15 pm
  • 4:30 pm
  • 5:00 pm
  • 5:15 pm
  • 5:30 pm

• Monday

• Start

  Date

• Finish

  Date

• Tuesday

• Start

  Date

• Finish

  Date

• Wednesday

• Start

  Date

• Finish

  Date

• Thursday

• Start

  Date

• Finish

  Date

• Friday

• Start

  Date

• Finish

  Date

• Saturday

• Start

  Date

• Finish

  Date

• Sunday

• Start

  Date

• Finish

  Date

Week 1

• Is the start and finish time the same each day?

  Yes

  No

• Days of the week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Start time each day:

  Select 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am 8:30 am 9:00 am 9:30 am

  • 6:00 am
  • 6:30 am
  • 7:00 am
  • 7:30 am
  • 8:00 am
  • 8:30 am
  • 9:00 am
  • 9:30 am

• Finish time each day:

  Select 3:00 pm 3:30 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm

  • 3:00 pm
  • 3:30 pm
  • 4:00 pm
  • 4:15 pm
  • 4:30 pm
  • 5:00 pm
  • 5:15 pm
  • 5:30 pm

• Monday

• Start

  Date

• Finish

  Date

• Tuesday

• Start

  Date

• Finish

  Date

• Wednesday

• Start

  Date

• Finish

  Date

• Thursday

• Start

  Date

• Finish

  Date

• Friday

• Start

  Date

• Finish

  Date

• Saturday

• Start

  Date

• Finish

  Date

• Sunday

• Start

  Date

• Finish

  Date

Week 2

• Is the start and finish time the same each day?

  Yes

  No

• Days of the week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Start time each day:

  Select 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am 8:30 am 9:00 am 9:30 am

  • 6:00 am
  • 6:30 am
  • 7:00 am
  • 7:30 am
  • 8:00 am
  • 8:30 am
  • 9:00 am
  • 9:30 am

• Finish time each day:

  Select 3:00 pm 3:30 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm

  • 3:00 pm
  • 3:30 pm
  • 4:00 pm
  • 4:15 pm
  • 4:30 pm
  • 5:00 pm
  • 5:15 pm
  • 5:30 pm

• Monday

• Start

  Date

• Finish

  Date

• Tuesday

• Start

  Date

• Finish

  Date

• Wednesday

• Start

  Date

• Finish

  Date

• Thursday

• Start

  Date

• Finish

  Date

• Friday

• Start

  Date

• Finish

  Date

• Saturday

• Start

  Date

• Finish

  Date

• Sunday

• Start

  Date

• Finish

  Date

Week 3

• Is the start and finish time the same each day?

  Yes

  No

• Days of the week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Start time each day:

  Select 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am 8:30 am 9:00 am 9:30 am

  • 6:00 am
  • 6:30 am
  • 7:00 am
  • 7:30 am
  • 8:00 am
  • 8:30 am
  • 9:00 am
  • 9:30 am

• Finish time each day:

  Select 3:00 pm 3:30 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm

  • 3:00 pm
  • 3:30 pm
  • 4:00 pm
  • 4:15 pm
  • 4:30 pm
  • 5:00 pm
  • 5:15 pm
  • 5:30 pm

• Monday

• Start

  Date

• Finish

  Date

• Tuesday

• Start

  Date

• Finish

  Date

• Wednesday

• Start

  Date

• Finish

  Date

• Thursday

• Start

  Date

• Finish

  Date

• Friday

• Start

  Date

• Finish

  Date

• Saturday

• Start

  Date

• Finish

  Date

• Sunday

• Start

  Date

• Finish

  Date

Week 1

• Is the start and finish time the same each day?

  Yes

  No

• Days of the week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Start time each day:

  Select 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am 8:30 am 9:00 am 9:30 am

  • 6:00 am
  • 6:30 am
  • 7:00 am
  • 7:30 am
  • 8:00 am
  • 8:30 am
  • 9:00 am
  • 9:30 am

• Finish time each day:

  Select 3:00 pm 3:30 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm

  • 3:00 pm
  • 3:30 pm
  • 4:00 pm
  • 4:15 pm
  • 4:30 pm
  • 5:00 pm
  • 5:15 pm
  • 5:30 pm

• Monday

• Start

  Date

• Finish

  Date

• Tuesday

• Start

  Date

• Finish

  Date

• Wednesday

• Start

  Date

• Finish

  Date

• Thursday

• Start

  Date

• Finish

  Date

• Friday

• Start

  Date

• Finish

  Date

• Saturday

• Start

  Date

• Finish

  Date

• Sunday

• Start

  Date

• Finish

  Date

Week 2

• Is the start and finish time the same each day?

  Yes

  No

• Days of the week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Start time each day:

  Select 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am 8:30 am 9:00 am 9:30 am

  • 6:00 am
  • 6:30 am
  • 7:00 am
  • 7:30 am
  • 8:00 am
  • 8:30 am
  • 9:00 am
  • 9:30 am

• Finish time each day:

  Select 3:00 pm 3:30 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm

  • 3:00 pm
  • 3:30 pm
  • 4:00 pm
  • 4:15 pm
  • 4:30 pm
  • 5:00 pm
  • 5:15 pm
  • 5:30 pm

• Monday

• Start

  Date

• Finish

  Date

• Tuesday

• Start

  Date

• Finish

  Date

• Wednesday

• Start

  Date

• Finish

  Date

• Thursday

• Start

  Date

• Finish

  Date

• Friday

• Start

  Date

• Finish

  Date

• Saturday

• Start

  Date

• Finish

  Date

• Sunday

• Start

  Date

• Finish

  Date

Week 3

• Is the start and finish time the same each day?

  Yes

  No

• Days of the week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Start time each day:

  Select 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am 8:30 am 9:00 am 9:30 am

  • 6:00 am
  • 6:30 am
  • 7:00 am
  • 7:30 am
  • 8:00 am
  • 8:30 am
  • 9:00 am
  • 9:30 am

• Finish time each day:

  Select 3:00 pm 3:30 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm

  • 3:00 pm
  • 3:30 pm
  • 4:00 pm
  • 4:15 pm
  • 4:30 pm
  • 5:00 pm
  • 5:15 pm
  • 5:30 pm

• Monday

• Start

  Date

• Finish

  Date

• Tuesday

• Start

  Date

• Finish

  Date

• Wednesday

• Start

  Date

• Finish

  Date

• Thursday

• Start

  Date

• Finish

  Date

• Friday

• Start

  Date

• Finish

  Date

• Saturday

• Start

  Date

• Finish

  Date

• Sunday

• Start

  Date

• Finish

  Date

Week 4

• Is the start and finish time the same each day?

  Yes

  No

• Days of the week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Start time each day:

  Select 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am 8:30 am 9:00 am 9:30 am

  • 6:00 am
  • 6:30 am
  • 7:00 am
  • 7:30 am
  • 8:00 am
  • 8:30 am
  • 9:00 am
  • 9:30 am

• Finish time each day:

  Select 3:00 pm 3:30 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm

  • 3:00 pm
  • 3:30 pm
  • 4:00 pm
  • 4:15 pm
  • 4:30 pm
  • 5:00 pm
  • 5:15 pm
  • 5:30 pm

• Monday

• Start

  Date

• Finish

  Date

• Tuesday

• Start

  Date

• Finish

  Date

• Wednesday

• Start

  Date

• Finish

  Date

• Thursday

• Start

  Date

• Finish

  Date

• Friday

• Start

  Date

• Finish

  Date

• Saturday

• Start

  Date

• Finish

  Date

• Sunday

• Start

  Date

• Finish

  Date

Work location

• The work location for this plan will be:

Supervisor

• Name:

• Phone number:

Signature of key people involved

• Worker: I will participate in these return to work arrangements.

  Sign

• Supervisor: I will implement these return to work arrangements in the work area

  Sign

• RTW Coordinator: I will monitor and review these return to work arrangements

  Sign

Signature Treating Medical Practitioner: (if required, i.e. no current medical clearance or employees capacity requires clarification)

• Treating medical practitioner: These return to work arrangements are consistent with the workers capacity

  Sign

Notes/additional information

• Is there any additional information about these return to work arrangements?