SAMPLE RETURN TO WORK LETTER
123 Any Street
This letter will serve to confirm the details of our meeting on ________________,
regarding your recent injury, and our agreement on a return to work plan for you
As we discussed, you will begin your return to work plan
effective__________________, at the following schedule:
Week 1 – 2 hours per scheduled shift
Week 2 – 4 hours per scheduled shift
Week 3 – 6 hours per scheduled shift
Week 4 – 8 hours per scheduled shift
Based on the information available from your doctor, the following restrictions are
placed on your work activity for the duration of this plan:
No repetitive bending at the waist
Avoid twisting movements at the waist
No lifting over 15 pounds
We discussed work duties that fall within these restrictions, and your supervisor has
indicated that she can accommodate you in your department with suitable work
duties. We agreed that you would be capable of performing the following duties:
You advised that you will be seeing your doctor again on ________________, and at
that time, it will be determined whether there are any changes to your abilities. You
agreed to notify us of the outcome, immediately following your appointment.
While you are participating in this return to work plan, you will be paid for the
hours you work. The Insurance Carrier will pay you for the hours you are unable
to work as a result of your injury. Based on this plan, you will be fully returned to
our payroll effective _____________________.
We had also agreed to meet as a team on _________________ to go over your
progress with this plan. In the meantime, should you be experiencing any difficulties
with this plan, I encourage you to notify me, discuss your concerns with your
supervisor, and notify your doctor if you experience any significant worsening of
your symptoms. We have reviewed the concept of “hurt versus harm”, and that you
can expect to feel somewhat sore as you begin increasing your activity. This is a
normal part of your recovery.
I want to wish you every success in your return to work plan. Please feel free to
contact me if you have any concerns or questions about this plan.
I can be reached at 123-4567.
cc. Insurance Company Case Manager
Pay and Benefits Department…for your information