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Return to Work Plan - E5

VIEWS: 4 PAGES: 1

									Company Name                             Company Address
                   TRANSITIONAL RETURN-TO-WORK PLAN FORM
Worker Name:

(DATES)FROM:                  TO:                  Review Date:

Scheduled Workdays                            Specific Duties to be Performed


Hours of Work


Treatment Appointments




Additional Equipment to be Provided




Any Additional Accommodations
Required




Activities to be Avoided




___________________         __________          ___________________       __________
Disabled Worker Signature   Date                Manager Signature               Date

								
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