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Work Release Sample
Return to Work Release and Work Ability
Employee Name: __________________________________________
Return to Work
Return to work with no limitations on ________/________/__________
Return to work with limitations on _________/_________/__________ (note limitations below)
Employee’s Capabilities
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Occasio |
Freque |
Continuo |
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Lift/Carry |
all |
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No lifting |
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Push/Pull without resistance |
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> 40 lbs |
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Bend |
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Twist/turn |
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Kneel/squat |
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Sit |
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Stand/walk |
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Ladder/stair |
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climb |
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Hand, wrist, and shoulder activities |
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Avoid prolonged, repetitive, or forceful: |
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Gripping/grasping |
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Repetitive wrist |
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motion |
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Reaching |
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Above |
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shoulder |
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At shoulder |
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height |
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Below |
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shoulder |
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This treatment has been discussed with the employee.
Restrictions (circle) |
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Keyboarding / hrs |
0 |
1 - 2 |
3 – 4 |
5 – 6 |
7+ |
Writing / hrs |
0 |
1 - 2 |
3 – 4 |
5 – 6 |
7+ |
Change positions every:
As needed
Half hour
One hour
Two hours
Worksite stretches
Exercises
Other
Comments:
_________________________________________________ |
__________________________ |
Physician Signature |
Date |
Instructions on Utilizing Work Release
Completing the Work Release form is an important step in ensuring that all necessary information is accurately captured. This form typically requires specific details about the individual seeking work release, the terms of employment, and any relevant dates. Following these steps will help you fill out the form correctly.
- Begin by entering your full name in the designated field at the top of the form.
- Provide your date of birth. Make sure to format it as requested, usually in MM/DD/YYYY.
- Next, fill in your contact information, including your phone number and email address.
- Indicate the name and address of your employer or the company where you will be working.
- Specify the position you will hold at the job and the expected start date.
- Detail the hours you will be working each day, including any specific days of the week.
- If applicable, include any information about transportation arrangements to and from work.
- Review the form for accuracy, ensuring all required fields are completed.
- Sign and date the form at the bottom to confirm that all information is true and correct.
Misconceptions
Understanding the Work Release form is essential for both employees and employers. However, several misconceptions often cloud its purpose and use. Here are four common misconceptions:
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It is only for employees with serious medical conditions. Many people believe that the Work Release form is exclusively for those who have undergone significant medical procedures or have severe health issues. In reality, it can apply to anyone needing temporary adjustments to their work schedule due to various circumstances, such as minor injuries or recovery from a short illness.
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Submitting a Work Release form guarantees job protection. While the form is a crucial step in notifying employers of an employee's need for modified work duties, it does not automatically ensure job security. Employers must still adhere to company policies and applicable labor laws, which may affect the employee's position during their recovery.
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Only healthcare professionals can fill out the form. A common belief is that only doctors or medical professionals can complete a Work Release form. However, the form can also be filled out by other qualified healthcare providers, such as nurse practitioners or physician assistants, depending on state regulations and company policies.
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The Work Release form is only needed for full-time employees. Some individuals think that the form is relevant only for those working full-time. This is not true. Part-time employees, interns, and even temporary workers may also require a Work Release form if they need to modify their work duties or schedules due to health-related issues.
By clarifying these misconceptions, individuals can better understand the importance of the Work Release form and its role in facilitating a smooth transition back to work after health-related absences.
Documents used along the form
The Work Release form is an important document that allows individuals to participate in work-related activities while fulfilling legal obligations. Several other forms and documents are often used in conjunction with the Work Release form to ensure compliance and facilitate the process. Below is a list of these documents along with brief descriptions of each.
- Employment Verification Form: This document confirms an individual's employment status, including job title, duration of employment, and hours worked. It is often required to validate the need for work release.
- Application for Work Release: This form is submitted by individuals seeking permission to work while serving a sentence. It includes personal information and details about the proposed employment.
- Release of Information Form: This document authorizes the sharing of an individual's personal and employment information with relevant parties, such as employers or legal authorities.
- Progress Report: This report provides updates on an individual’s work performance and compliance with the terms of their work release. It may be required periodically.
- Incident Report: In the event of any issues or violations during the work release period, this form documents the incident and is submitted to the appropriate authorities.
- New York DTF 84 Form: This application is essential for businesses aiming to receive sales tax certification as a Qualified Empire Zone Enterprise (QEZE). Understanding how to properly complete the application is crucial. For more information, visit https://nypdfforms.com/new-york-dtf-84-form.
- Compliance Agreement: This document outlines the rules and expectations that individuals must follow while on work release. It is signed by both the individual and supervising authority.
- Termination Notice: If an individual's work release is revoked, this notice formally communicates the termination and the reasons for it.
- Job Description: This document details the responsibilities and duties associated with the individual's job. It may be required to ensure the work aligns with the terms of the work release.
These documents serve various purposes, from verifying employment to ensuring compliance with legal requirements. Together, they create a framework that supports individuals seeking to work while managing their legal obligations.