PHYSICIAN’S RELEASE TO RETURN TO WORK FORM

Employee’s Name: | Date: 06/14/2014 | Physician’s Name: | Telephone: 832-604-3300 |

To be completed by Physician

After reviewing the attached job description and the specific tasks within the job description please complete either (A) or (B) as appropriate and sign and date below.

(A) The above named employee has been released by the above named

Physician to return to Full Duty as of with NO RESTRICTIONS. 06/16/2014(Date)

(B) The above named employee has been released by the above named

Physician to Return to Work on (Date) WITH THE

FOLLOWING RESTRICTIONS through (Date):

Check applicable boxes and provide limitations/restrictions. | † Lifting (Max weight in lbs) lbs. | † Walking hours per day | † Repetitive Lifting lbs. | † Standing hours per day | † Carrying lbs. | † Sitting hours per day | † Pushing/pulling lbs. | † Crawling hours per day | † Pinching/Gripping lbs. | † Kneeling hours per day | † Reaching over head | † Squatting hours per day | † Reaching away from body | † Climbing hours per day | † Repetitive Motion Restrictions: | † Other Restrictions: | These limitations/restrictions are: | † Temporary limitations/restrictions† Permanent limitations/restrictions |

IF THE ABOVE RESTRICTION CONSTITUTE MODIFIED DUTY AND SUCH DUTY IS NOT AVAILABLE, IT IS ASSUMED THAT THE EMPLOYEE WILL BE SENT HOME RATHER THAN RETURN TO WORK. My signature indicates that I have read and understand the employee’s job description and the listed tasks within the job description and that my findings are based on my medical assessment of this employee’s physical capabilities as compared to the essential functions of the job.

Physician’s Name (Please Print): | | Physician’s Signature: | | Date: | |

I AGREE THAT:
I will follow through with all of the restrictions listed above. I will notify my supervisor of any departure from these restrictions. Employee’s Signature: | | Date: | |