Return to Work Plan form - DOC - DOC

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Return to Work Plan form - DOC - DOC Powered By Docstoc
					                                                                                                                   Return To Work Plan
To be completed by Supervisor or Human Resources Consultant for all employees returning to work, including
those with a request for work accommodations.


SECTION A: EMPLOYEE INFORMATION
Employee Name:

SECTION B: REQUEST FOR ACCOMMODATION                                                                                                    (FAQ’s)
                                                           MM        DD           YY

Date of initial request for accommodation:

SECTION C: EMPLOYEE MEDICAL INFORMATION                                                                                                 (FAQ’s)
                                      MM     DD         YY

                                                                      Health Care
Date of Medical Note:
                                                                    Provider’s Name:

Medical Restriction(s):

                                                      MM        DD           YY

Expected Date of Return to Regular Work:
                                                                                                                                   MM   DD    YY

Is the limitation:         Permanent              Temporary        If Temporary, indicate expected duration of modified duties:

COMMENTS:




SECTION D: PLAN GOALS
Goal is to return employee to pre-disability status. Please check all applicable boxes:

                                             MM         DD           YY                                                            MM   DD    YY
     To return to full-time regular                                                    To return to part-time modified
     duties as of:                                                                     duties as of:
                                             MM         DD           YY                                                            MM   DD    YY
     To return to full-time modified
     duties as of:
                                                                                  Medical Progress Review to occur on:

SECTION E: DESCRIPTION OF REGULAR JOB DUTIES
Position classification:

Essential job tasks include:




APS Return to Work Guidelines – Return to Work Plan (Pages 5A-6 – 5A-10)                                                                          5A-7
SECTION F: DESCRIPTION OF WORK ACCOMMODATION DUTIES                                                                      (FAQ’s)
Position classification:

Essential job tasks include: (FAQ’s)



                                                                                                                    MM   DD    YY

     Job description for modified duties and/or Return to Work Plan.       Reviewed by Health Care Provider:
                                                                           (FAQ’s)
                                                                                                                    MM   DD    YY

Hours of Work:                                                             Progress review will occur on:
                                                                           (FAQ’s)

Skills or Training Required:



SECTION G: ADDITIONAL COMMENTS
[Add comments here.]
SECTION H: SIGNATURES                                                                                                    (FAQ’s)

 Employee’s Name (please print)

 Date:                                                                                                  Signature



 Supervisor’s Name (please print)

 Date:                                                                                                  Signature



 Union Representative Name (please print)

 Date:                                                                                                  Signature



 NOTE: If the employee has made a request for further or different accommodation, new medical information
       should be requested; and a new Return to Work Plan should be initiated.




APS Return to Work Guidelines – Return to Work Plan (Pages 5A-6 – 5A-10)                                                           5A-8