Return to Work Plan Template

• Employee Name

• Claim #

• Conducted on

  Date

• Prepared by

• Location
  Address

• Injury Date

• Pre-Injury Job

• Pre-Injury Workplace Location
  Address

Return to Work Goal

• Plan Start Date

  Date

• Plan End Date

  Date

• Return To Work Plan Goal

  Pre-injury job

  Pre-injury job, accomodated

  Alternate Work

• Please provide work description

Health Recovery

• Accepted area(s) of injury

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

  Yes

  No

  N/A

• Please provide details

Health Professional Contact Person

• Name

• Contact Details

Functional Abilities

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

Functional Ability

• Type

• Precaution

• Job duties that worker is able to perform

• Job duties that worker is unable to perform

Accommodations/Solutions

• Are accommodations to the job duties required?

  Yes

  No

  N/A

• Are accommodations to the workplace/workstation required?

  Yes

  No

  N/A

• Is training required?

  Yes

  No

  N/A

• Provide details on the type of accommodation/solution required.

Training/Accommodation

• Training/Accommodation

• Date of Implementation

  Date

• Expected Duration

Work Schedule

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

• List follow-up dates to monitor progress

Sign-off

• Employee Name and Signature

  Sign

• Date Signed

  Date

• Supervisor Name and Signature

  Sign

• Date Signed

  Date