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Return To Work Clearance Form

Return To Work Clearance Form Template for New Zealand

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Key Requirements PROMPT example:

Return To Work Clearance Form

"I need a Return To Work Clearance Form for an office worker returning from a 6-week medical leave due to a back injury, requiring basic workplace ergonomic modifications and restricted lifting duties."

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Document background
The Return To Work Clearance Form is a critical document used in New Zealand workplaces to manage the safe and effective return of employees following illness, injury, or extended absence. It aligns with New Zealand's Health and Safety at Work Act 2015, Privacy Act 2020, and other relevant legislation, ensuring proper documentation of medical clearance and any necessary workplace accommodations. This form is essential when an employee has been absent due to medical reasons and requires formal clearance to resume duties. It captures crucial information including medical practitioner's assessment, work capacity details, required workplace modifications, and relevant timeframes. The document helps organizations fulfill their duty of care obligations while protecting employee wellbeing and managing potential liability risks.
Suggested Sections

1. Employee Information: Employee's personal details including name, position, department, and employee ID

2. Absence Information: Details of the absence period, including start date and nature of illness/injury (without specific medical details)

3. Medical Practitioner Declaration: Healthcare provider's clearance statement and contact details

4. Work Capacity Assessment: Clear statement of employee's fitness for work (full duties/restricted duties)

5. Required Workplace Adjustments: Any necessary modifications or restrictions to regular duties

6. Duration of Adjustments: Timeframe for any workplace modifications or restrictions

7. Authorization: Signatures from employee, medical practitioner, and date of clearance

Optional Sections

1. Graduated Return to Work Plan: Detailed schedule for phased return to full duties, used when employee requires gradual reintegration

2. Specific Task Restrictions: Detailed list of tasks that must be avoided or modified, used when specific job components are affected

3. Follow-up Requirements: Schedule of follow-up assessments or reviews, used for ongoing monitoring needs

4. ACC Claim Details: ACC claim number and relevant details, used when absence was due to an ACC claim

5. Workplace Rehabilitation Plan: Detailed rehabilitation requirements and timeline, used for complex recovery situations

Suggested Schedules

1. Medical Certificate: Attached medical certificate from healthcare provider

2. Task Analysis Form: Detailed breakdown of job requirements and physical demands

3. Risk Assessment: Assessment of workplace risks related to the employee's condition

4. Rehabilitation Plan: Detailed plan for ongoing rehabilitation requirements if applicable

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok³ÉÈË°æ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co
Relevant legal definitions

























Clauses















Relevant Industries

Healthcare

Manufacturing

Construction

Education

Retail

Professional Services

Public Sector

Transport and Logistics

Mining and Resources

Agriculture

Hospitality

Information Technology

Financial Services

Relevant Teams

Human Resources

Health and Safety

Risk Management

Operations

Occupational Health

Employee Relations

Compliance

People and Culture

Relevant Roles

HR Manager

Health and Safety Manager

Return to Work Coordinator

Occupational Health Nurse

HR Business Partner

Risk Manager

Operations Manager

Line Manager

Department Supervisor

Workplace Health and Safety Officer

Human Resources Director

Employee Relations Manager

Compliance Officer

Industries






Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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