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Return To Work Medical Evaluation Form

To receive medical verification from your employees have their medical professional fill out the form below.

Return To Work Medical Evaluation Form

Return To Work Medical Evaluation Form

Employee's Name:

_________________________ ID# ___

Date of injury/surgery/onset or onset of illness: __/__/___ Date of Exam: ______

Diagnosis or description of injury/surgery/illness:


The patients return to work status is:

[___] Return to regular work. Date: ____/____/____

[___] Able to return to work with noted restrictions. Date: ____/____/____

[___] Unable to return to work until next evaluation. Date: ____/____/____

[___] Referred to health care provider. Name ________ Date: ____/____/____

Lifting Restrictions:

[___] None
[___] 40 - 50 lbs.
[___] 30 - 39 lbs.
[___] 20 -29 lbs.
[___] 10 - 19 lbs.

Follow Up Plan of Treatment:

[___] None

[___] Return visit on: ______________ at________a.m./p.m.

Additional Comments:




Health Care Provider's Signature


Print Name

_______________________ Date_____

Phone Number: ____________________

Address: _________________________

City: __________ State: ___ Zip: ____



Agreements & References

Return To Work Form

Agreement To Return

Non Disclosure Agreement

Non Compete Agreement

Sign On Bonus Contract

Financial Conflict of Interest Disclosure

Employee References

Employee Background Check

Military Statement of Service

Employee Handbook Outline

Temporary Employment Agreement

Medical Evaluation Work Return Letter

Temps & Telecommuting

Temp Agency Checklist

Telecommuting Policies

Telecommuting Agreement

Sample Resumes & Letters

Job Application Cover Letter

Job Application Letters

Sample Resume Format


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