Return-to-Work Review Form
Document Control Company: [COMPANY NAME] · Logo: [COMPANY LOGO] · Address: [COMPANY ADDRESS] Prepared by: [RESPONSIBLE PERSON] · Date: [DATE] · Approved by (signature): _________________
| Field | Value |
|---|---|
| Category | Incident and Near Miss Reporting |
| Recommended Industry | All |
| Document Type | Form |
| Access Level | Starter |
| Last Reviewed | 2026-06-29 |
| Last Updated | 2026-06-29 |
How to Use This Template
Complete the fields as fully and accurately as possible at the time of the task or event. Route the completed document per your internal process and retain it with your records.
Template Body
Use when an injured employee returns, including transitional/modified duty.
| Field | Entry |
|---|---|
| Employee: | [NAME] |
| Injury / date: | [____] |
| Provider restrictions: | [____] |
| Modified-duty assignment offered: | [____] |
| Tasks within restrictions? | ☐ Yes |
| Start date of return: | [DATE] |
| Follow-up/review date: | [DATE] |