Return to Work Plan

• Employee Name

• Department

• Conducted on

  Date

• Prepared by

• Injury Date

  Date

• Pre-Injury Role

• Pre-Injury Workplace Location

Return to Work Goal

• Plan Start Date

  Date

• Return To Work Plan Goal

  Select Pre-injury job Pre-injury job - with agreed limitations Alternate Work

  • Pre-injury job
  • Pre-injury job - with agreed limitations
  • Alternate Work

• Please provide alternate work description

• Describe agreed general adjustments to work

Health Recovery

• Agreed area(s) of injury

• Is there an active treatment plan that impacts return to work?

  Yes

  No

  N/A

• Please provide details

Functional Abilities

• Add tasks for the role and complete the fields accordingly.

Functional Ability

• Task

• Ability affected?

  Can perform

  Can Perform with adjustments

  Cannot Perform

• List adjustments

• Additional Precautions or Adjustments required?

  Yes

  No

  N/A

• Detail precautions and adjustments

Accommodations/Solutions

• Are other adjustments to the work duties required?

  Yes

  No

  N/A

• Details of adjustments

• Are Adjustments to the work schedule required?

  Yes

  No

  N/A

• Details

• Are Adjustments to the work area required?

  Yes

  No

  N/A

• Details

• Are Adjustments to the work station required?

  Yes

  No

  N/A

• Details

• Image of workstation and area

  Media

• Is training required?

  Yes

  No

  N/A

• Detail

Training/Accommodation

• Training/Adjustment

• Date of Implementation

  Date

• Expected Duration

Sign-off

• The asessee has provided accurate information to the best of their knowledge. This assessment may be reviewed and updated by request of either the assessee or supervisor. Signees indicate their acceptance of the recorded actions and inofrmation.

• Employee Name and Signature

  Sign

• Date Signed

  Date

• Supervisor Name and Signature

  Sign

• Date Signed

  Date

• Completed by

  Sign