Return to Work Plan

Injury Date

Pre-Injury Job

Pre-Injury Workplace Location
Return to Work Goal
Plan Start Date
Plan End Date

Return To Work Plan Goal

Please provide work description

Health Recovery

Accepted area(s) of injury

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

Please provide details

Health Professional Contact Person


Contact Details

Functional Abilities

Add functional abilities that the worker can do and fill-out the fields accordingly.

Functional Ability



Job duties that worker is able to perform

Job duties that worker is unable to perform


Are accommodations to the job duties required?

Are accommodations to the workplace/workstation required?

Is training required?

Provide details on the type of accommodation/solution required.



Date of Implementation

Expected Duration

Work Schedule

Upload here a picture of the planned work schedule of the employee.

List follow-up dates to monitor progress

Employee Name and Signature
Date Signed
Supervisor Name and Signature
Date Signed
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.