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Return To Work Medical Evaluation Form
"I need a Return to Work Medical Evaluation Form for our manufacturing facility that includes detailed physical capability assessments and safety protocols, specifically for employees returning from long-term disability, with extra emphasis on machinery operation clearance."
1. Employee Information: Basic identification details including name, employee ID, department, and position
2. Absence Information: Details about the period of absence, reason for absence, and last day worked
3. Consent and Authorization: Employee's consent for collection and sharing of medical information
4. Healthcare Provider Information: Treating physician's contact information and credentials
5. Medical Assessment: Current medical status, diagnosis (where appropriate to share), and prognosis
6. Functional Capabilities: Detailed assessment of physical and cognitive capabilities and limitations
7. Work Restrictions: Specific restrictions and accommodations required for safe return to work
8. Return to Work Plan: Recommended timeline and progression for return to work
9. Certification: Healthcare provider's signature and date confirming assessment
1. Workplace Injury Details: Used when the absence is due to a workplace injury or illness, including WCB/WSIB claim information
2. Medication Impact Assessment: Required when prescribed medications may affect work performance or safety
3. Mental Health Considerations: Included when mental health factors need to be addressed in the return to work plan
4. Physical Therapy Requirements: Added when ongoing physical therapy or rehabilitation is part of the recovery plan
5. Job-Specific Assessment: Detailed evaluation of ability to perform specific job duties, used for specialized roles
1. Schedule A - Physical Demands Assessment: Detailed checklist of physical requirements for the employee's role
2. Schedule B - Functional Abilities Form: Standardized form detailing specific functional abilities and limitations
3. Schedule C - Workplace Modification Guide: List of available workplace modifications and accommodations
4. Appendix 1 - Follow-up Schedule: Timeline for follow-up assessments and progress reviews
5. Appendix 2 - Emergency Protocols: Procedures to follow if medical conditions require emergency response
Authors
Manufacturing
Construction
Healthcare
Transportation
Mining
Retail
Warehousing
Public Sector
Education
Forestry
Oil and Gas
Agriculture
Hospitality
Maritime
Human Resources
Occupational Health and Safety
Risk Management
Employee Relations
Benefits Administration
Medical Services
Operations
Legal
Workers' Compensation
Disability Management
Human Resources Manager
Occupational Health and Safety Manager
Disability Management Coordinator
Return to Work Specialist
HR Business Partner
Health and Safety Coordinator
Employee Relations Manager
Workers' Compensation Coordinator
Occupational Health Nurse
Risk Manager
Benefits Administrator
Labour Relations Manager
Operations Manager
Department Supervisor
Medical Office Administrator
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