Return to Work Form
To be completed by MEDICAL PROVIDER and returned to employer immediately following each appointment.
Patient Name: _____________________________________________
Today’s Date: ______/______/______
Employer: ________________________________________________
Date of Birth: ______/______/______
Occupation: _______________________________________________
Date of Injury: ______/______/______
Diagnosis/Impression: ______________________________________________________
Patient can return to work
With limitations on: ________________________________________________
Without limitations on: _____________________________________________
Patient is off work: ____________________________________
Comments:
Next Appointment: _____________________
_______________________________________________________________________________
_______________________________________________________________________________
Signature _____________________________________________
______________________________________________________
Provider ______________________________________________
_______
Signature D E G R E E
Sedentary Work::
Lifting up to 10 pounds occasionally
and frequently lifting and/or carrying
such articles as dockets, ledgres, and
small tools. Although a sedentary job
is defined as one which involves
sitting, a certain amount of walking
and standing is often necessary in
carrying out job duties. Jobs are
sedentary if walking and standing are
required only occasionally and other
sedentary criteria are met.
Light Work:
Lifting up to 20 pounds occasionally
with frequent lifting and/or carrying of
objects weighing up to 10 pounds.
Even though the weight lifted may be
only a negligible amount, a job is in
this category when it requires walking
or standing to a significant degree or
when it involves sitting most of the
time with a degree of pushing and pull
of arm and/or leg controls.
Date: ______/_______/_______
Phone: (
L I M I T AT I O N S
Heavy Work:
Lifting up to 50 pounds occasionally,
with frequent lifting and/or carrying of
objects weighing up to 50 pounds.
Very Heavy Work:
Lifting objects in excess of 100 pounds
occasionally, with frequent lifting
and/or carrying of objects weighing 50
pounds or more, exerting 20 lbs of
force constantly.
Work compatible with splints,
braces, cast, bandages, crutches
RAS-01-0012
Rev 01/11
-
-
L I M I T AT I O N S ( C O NT .)
Other:
1. In a ______ hour work day patient may:
a. Stand/Walk
None
6-8 Hours
1-4 Hours
8-10 Hours
4-6 Hours
10+ Hours
1-3 Hours
3-5 Hours
5-8 Hours
8-10 Hours
b. Sit
DEFINITIONS
c. Drive
1-3 Hours
3-5 Hours
5-8 Hours
8-10 Hours
10+ Hours
2. Patient may use injured hand for:
Never Rare Occ Freq Cont
Simple Grasping
Fine Manipulation
Medium Work:
Lifting up to 50 pounds occasionally,
with frequent lifting and/or carrying of
objects weighing up to 25 pounds.
)
In an 8 hour period:
Rarely
0-10% of time (=45 min)
Less than 6 reps per hour
Occasionally
11-33% of time (=50-100 min)
7-19 reps per hour
Frequently
34-67% (+150-300 min)
20-40 reps per hour
Continously
68-100% (=300-450 min)
40+ reps per hour
Pushing/Pulling
CONDITION
Firm Grasping:
Patient is not to use injured hand.
Worse
Discharged
3. Patient is able to:
Improved
Bend
Resolved
Squat
Climb Stairs
No change in:
Reach Above Shoulder
Kneel
Diagnosis
Treatment
4. Patient may use feet for repetitive movement
as in operation foot controls:
Yes
No
Work Restriction
OFFICES IN SOUTH DAKOTA AND MINNESOTA
Mailing Address: PO Box 89310, Sioux Falls, SD 57109-9310
P. 800.732.1486 F. 877.884.6573
www.rascompanies.com
RAS-01-0012
Rev 01/11
OFFICES IN SOUTH DAKOTA AND MINNESOTA
Mailing Address: PO Box 89310, Sioux Falls, SD 57109-9310
P. 800.732.1486 F. 877.884.6573
www.rascompanies.com