Workers' Compensation Return to Work Release
RETURN TO WORK RELEASE
(Workers' Compensation Medical Authorization)
SECTION 1: DOCUMENT HEADER
DATE OF RELEASE: [DATE]
CLAIM NUMBER: [CLAIM NUMBER]
TYPE OF RELEASE:
☐ Full Duty Release - No Restrictions
☐ Modified/Light Duty Release - With Restrictions
☐ Conditional Release - Subject to Accommodation
☐ Progressive Return - Graduated Increase in Duties
SECTION 2: PATIENT/EMPLOYEE INFORMATION
Patient Name: [FULL NAME]
Date of Birth: [DATE]
Social Security Number (Last 4): XXX-XX-[LAST 4]
Date of Injury: [DATE]
Employer: [EMPLOYER NAME]
Job Title: [JOB TITLE]
SECTION 3: PHYSICIAN INFORMATION
Physician Name: [NAME], [CREDENTIALS]
Specialty: [SPECIALTY]
License Number: [NUMBER]
Practice Name: [PRACTICE NAME]
Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]
Phone: [PHONE NUMBER]
Fax: [FAX NUMBER]
SECTION 4: MEDICAL RELEASE DETAILS
4.1 Release Status
Effective Date of Release: [DATE]
Medical Status:
☐ Patient has reached Maximum Medical Improvement (MMI)
☐ Patient is improving but has not reached MMI
☐ Patient requires ongoing treatment while working
☐ Patient is medically stable for work activities within restrictions
4.2 Work Capacity Determination
This patient is cleared to return to:
☐ FULL DUTY
The patient may return to their regular job duties without any restrictions effective [DATE].
☐ MODIFIED DUTY WITH RESTRICTIONS
The patient may return to work with the restrictions specified below effective [DATE] through [END DATE OR "UNTIL FURTHER NOTICE"].
☐ PART-TIME/REDUCED HOURS
The patient may work [NUMBER] hours per day, [NUMBER] days per week.
☐ GRADUATED RETURN
The patient should gradually increase work activities as follows:
Week 1: [HOURS/RESTRICTIONS]
Week 2: [HOURS/RESTRICTIONS]
Week 3: [HOURS/RESTRICTIONS]
Week 4: [HOURS/RESTRICTIONS]
SECTION 5: WORK RESTRICTIONS AND LIMITATIONS
5.1 Physical Restrictions
Lifting/Carrying:
☐ No restrictions
☐ No lifting over [___] pounds
☐ No lifting over [___] pounds above shoulder height
☐ No lifting over [___] pounds below knee level
☐ No repetitive lifting
☐ Two-person lift required for items over [___] pounds
Pushing/Pulling:
☐ No restrictions
☐ No pushing/pulling over [___] pounds of force
Posture and Movement:
| Activity | No Restriction | Limited | Avoid Completely |
|---|---|---|---|
| Standing | ☐ | ☐ Max [___] hours/day | ☐ |
| Walking | ☐ | ☐ Max [___] hours/day | ☐ |
| Sitting | ☐ | ☐ Max [___] hours/day | ☐ |
| Bending/Stooping | ☐ | ☐ Occasional only | ☐ |
| Twisting/Rotating | ☐ | ☐ Occasional only | ☐ |
| Squatting/Kneeling | ☐ | ☐ Occasional only | ☐ |
| Climbing (stairs) | ☐ | ☐ Limited | ☐ |
| Climbing (ladders) | ☐ | ☐ Limited | ☐ |
| Balancing | ☐ | ☐ Limited | ☐ |
| Crawling | ☐ | ☐ Limited | ☐ |
Upper Extremity Restrictions:
| Activity | No Restriction | Left Only | Right Only | Both |
|---|---|---|---|---|
| Reaching above shoulder | ☐ | ☐ Restrict | ☐ Restrict | ☐ Restrict |
| Reaching forward | ☐ | ☐ Restrict | ☐ Restrict | ☐ Restrict |
| Repetitive gripping | ☐ | ☐ Restrict | ☐ Restrict | ☐ Restrict |
| Fine manipulation | ☐ | ☐ Restrict | ☐ Restrict | ☐ Restrict |
| Keyboarding/typing | ☐ | ☐ Limit to [___] hrs | ☐ Limit to [___] hrs | ☐ Limit to [___] hrs |
Lower Extremity Restrictions:
☐ No restrictions
☐ No prolonged standing (limit to [___] minutes at a time)
☐ Limit walking to [___] feet/yards at a time
☐ No climbing
☐ No operating foot controls
☐ Use of assistive device required: [SPECIFY]
5.2 Environmental Restrictions
☐ No restrictions on work environment
Temperature:
☐ Avoid extreme heat (over [___]°F)
☐ Avoid extreme cold (under [___]°F)
☐ Avoid temperature fluctuations
Exposure:
☐ Avoid dust/particulates
☐ Avoid fumes/gases
☐ Avoid chemicals: [SPECIFY]
☐ Avoid loud noise
☐ Avoid vibration
☐ Avoid heights over [___] feet
☐ Avoid confined spaces
5.3 Work Schedule Restrictions
Hours:
☐ No restrictions on hours
☐ Maximum [___] hours per day
☐ Maximum [___] hours per week
☐ No overtime
☐ Mandatory rest breaks every [___] hours for [___] minutes
Shifts:
☐ No restrictions on shifts
☐ Day shift only
☐ No rotating shifts
☐ No night shifts
5.4 Activity-Specific Restrictions
☐ No driving (work-related)
☐ May drive for [___] minutes maximum
☐ No operating heavy machinery
☐ No operating power tools
☐ No work at heights
☐ No working alone
☐ Other: [SPECIFY]
5.5 Additional Accommodations Recommended
[DESCRIBE ANY ADDITIONAL ACCOMMODATIONS]
Examples:
- Ergonomic workstation
- Sit/stand desk
- Frequent position changes
- Specific seating requirements
- Anti-fatigue mat
- Modified tools/equipment
____________________________________________________________________________
____________________________________________________________________________
SECTION 6: DURATION OF RESTRICTIONS
Restrictions Are:
☐ Temporary - Expected to be lifted on approximately [DATE]
☐ Temporary - Until next medical evaluation on [DATE]
☐ Temporary - Duration unknown, reassess in [___] weeks
☐ Permanent - These restrictions are expected to be permanent
Next Re-Evaluation Date: [DATE]
SECTION 7: ONGOING MEDICAL TREATMENT
Will Patient Require Ongoing Medical Treatment While Working?
☐ No
☐ Yes - Specify below
Type of Ongoing Treatment:
☐ Physical Therapy: [___] times per week
☐ Occupational Therapy: [___] times per week
☐ Medical Follow-up: Every [___] weeks
☐ Medication Management
☐ Other: [SPECIFY]
Treatment Schedule Accommodations Needed:
[DESCRIBE ANY TIME-OFF NEEDS FOR MEDICAL APPOINTMENTS]
SECTION 8: JOB ANALYSIS RESPONSE (EMPLOYER COMPLETION)
8.1 Essential Job Functions Review
Job Title: [JOB TITLE]
Can the employee perform the essential functions of their regular job within the stated restrictions?
☐ Yes - Employee can perform all essential functions
☐ No - Essential functions exceed stated restrictions
☐ Partial - Employee can perform some essential functions
8.2 Modified Duty Availability
Is modified/light duty work available within restrictions?
☐ Yes - Modified duty position available
☐ No - No modified duty available at this time
If Yes, describe modified duty position:
Position Title: [TITLE]
Department: [DEPARTMENT]
Supervisor: [NAME]
Start Date: [DATE]
Duration: [DURATION]
Description of Modified Duties:
____________________________________________________________________________
____________________________________________________________________________
8.3 Employer Certification
Employer Representative: [NAME]
Title: [TITLE]
Date: [DATE]
Signature: _________________________________
SECTION 9: PHYSICIAN CERTIFICATION
I, [PHYSICIAN NAME], [CREDENTIALS], certify that:
☐ I have examined the patient on [DATE].
☐ Based on my examination and review of medical records, the patient is medically cleared to return to work as indicated above.
☐ The restrictions specified above are medically necessary to prevent re-injury or worsening of the patient's condition.
☐ These restrictions are based on objective medical findings.
☐ I have reviewed the patient's job description/job analysis: ☐ Yes ☐ No ☐ Not Provided
Physician Signature: _________________________________
Printed Name: [NAME], [CREDENTIALS]
Date: [DATE]
License Number: [NUMBER]
SECTION 10: EMPLOYEE ACKNOWLEDGMENT
I, [EMPLOYEE NAME], acknowledge that:
☐ I have received a copy of this Return to Work Release.
☐ I understand the work restrictions placed on me by my physician.
☐ I agree to abide by these restrictions and will not perform activities outside the stated limitations.
☐ I will immediately report any increase in symptoms or pain to my supervisor and treating physician.
☐ I understand that failure to follow these restrictions may result in re-injury and may affect my workers' compensation benefits.
☐ I understand that I should notify my employer and physician if the modified duty position requires me to exceed these restrictions.
Employee Signature: _________________________________
Date: [DATE]
SECTION 11: IMPORTANT NOTICES
For the Employee:
-
Follow Your Restrictions: You must not perform work activities that exceed the restrictions listed in this release. Doing so may result in re-injury and could affect your eligibility for workers' compensation benefits.
-
Report Problems Immediately: If you experience increased pain, new symptoms, or feel that your work duties are exceeding your restrictions, notify your supervisor immediately and contact your treating physician.
-
Attend Medical Appointments: Continue to attend all scheduled medical appointments and follow your treatment plan.
-
Communicate with Your Employer: Work with your employer to ensure your modified duty assignment stays within your restrictions.
For the Employer:
-
Accommodate Restrictions: The employer should make reasonable efforts to accommodate the stated restrictions.
-
Monitor the Employee: Supervisors should ensure the employee's duties remain within the stated restrictions.
-
Document Modified Duty: Maintain records of modified duty assignments and any issues that arise.
-
Report Changes: Notify the insurance carrier and treating physician of any changes in the employee's work status.
State-Specific Notices:
California: If modified/alternative work is not offered within 60 days of receipt of a Physician's Return-to-Work & Voucher Report, the employee may be entitled to a Supplemental Job Displacement Benefit (SJDB) voucher.
Texas: The employer must notify the Division of Workers' Compensation if modified duty is offered and refused.
[YOUR STATE]: [INSERT STATE-SPECIFIC NOTICE]
DISTRIBUTION
☐ Original to Employee
☐ Copy to Employer/HR Department
☐ Copy to Supervisor
☐ Copy to Workers' Compensation Insurance Carrier
☐ Copy retained in Physician's Medical Records
[END OF DOCUMENT]
About This Template
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Important Notice
This template is provided for informational purposes. It is not legal advice. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Last updated: April 2026