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Return To Work Agreement

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Return To Work Agreement Template

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Return To Work Agreement

Date: ____/____/______

Employee’s Name: ____________________________________________________

Department: _________________________________________________________

Supervisor’s Name: ___________________________________________________

Supervisor’s Phone: _______________ Supervisor’s Mobile: __________________

Dear __________________________,

We have recently received your official medical release from ______________________, and dated ____/____/______, and we are very pleased you are able to return to work. Your release form states that you may return to work with the following medical restrictions:




Your department is able to accommodate the above mentioned work restrictions for the following period of time:

Employment Starting on: ____/____/______ and Ending on: ____/____/______ for a total number of _____ working days. This is a transitional employment assignment and shall not exceed more than 90 days, without your medical condition improving. Your alternative employment arrangement is as follows:



This is not a permanent position. It was created specifically to help you with returning to work following your medical leave. It is with the understanding that at the end of this specific time period, you will have complete medical clearance to return to full duty without any work restrictions. It is also further understood that you agree to the following:

1. Work within the medical restrictions and follow all medical instructions.

2. Have periodic medical re-evaluations as needed and prescribed by your doctor.

3. Have periodic job performance reviews in verbal or written format.

4. Have a progressive increase in the amount of duties as your written medical documents allow.

Any extension of this Agreement beyond the above listed dates will be decided on a case by case basis and will be based on additional information from your doctor and upon the needs of the department at that future date. This transitional employment in no way implies that we are obligated to continue your employment indefinitely with these current conditions.

Signature of Employee

Signature of Supervisor

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