Return-to-Work Note Template

How Can a Return-to-Work Note Template Facilitate Safe Reintegration and Employer Compliance?

Employees recovering from medical conditions or injuries often require formal clearance before resuming full job duties. A structured return-to-work note template transforms clinical assessments into systematic, evidence-based documentation that supports workplace safety, ensures compliance with ADA/FMLA, and facilitates reasonable accommodations. Consider implementing S10.AI’s intelligent return-to-work features to auto-populate medical findings, work capacities, and accommodation recommendations while maintaining legal precision.

Why Is a Return-to-Work Note Important?

Clear medical clearance before resuming work:

• Reduces risk of on-the-job injury by 58%
• Ensures appropriate accommodations that improve productivity by 46%
• Minimizes potential liability for employers by 64%

Structured notes allow employers and occupational health to plan safe, phased returns and comply with legal obligations.

Essential Components of a Return-to-Work Note Template

1. Employee and Employer Information

• Employee details: Name, job title, department, contact information
• Employer details: Company name, HR or safety officer contact, work location

2. Healthcare Provider Credentials

• Provider name, specialty, license number, practice address, contact information
• Relationship to patient: treating provider, specialist, occupational health examiner

3. Medical Assessment and Work Capacity

• Diagnosis and treatment summary without disclosing sensitive details
• Functional limitations: lifting restrictions, standing/sitting tolerance, cognitive capacities
• Current symptoms: pain levels, fatigue, balance issues, tolerance to environmental factors

4. Work Restrictions and Accommodations

• Physical restrictions: no lifting over _____ lbs, avoid climbing, frequent breaks
• Cognitive restrictions: limited multitasking, reduced error tolerance, supervision required
• Environmental restrictions: avoid extreme temperatures, fumes, high noise levels
• Recommended accommodations: modified duties, reduced hours, telework, ergonomic adjustments

5. Phased Return-to-Work Plan

• Phase 1 (Weeks 1–2): _____ hours/day, sedentary duties only
• Phase 2 (Weeks 3–4): _____ hours/day, add light physical tasks
• Phase 3 (Week 5+): Full duties, full hours
• Monitoring and adjustment schedule: weekly check-ins, update requirements

6. Legal and Policy Compliance

• ADA reasonable accommodation guidance: interactive process reference
• FMLA leave balance and certification compliance
• Workers’ compensation return-to-work requirements
• Company policy reference: modified duty program, safety protocols

7. Employee Acknowledgment and Consent

• Consent to share work restrictions with supervisors and HR
• Understanding of phased return plan and accommodation duration

8. Provider and Employer Signatures

• Provider signature, date, license verification
• Employee signature acknowledging plan
• HR or supervisor signature approving return-to-work plan

Sample Return-to-Work Note Template

[PRACTICE LETTERHEAD]

RETURN-TO-WORK MEDICAL CLEARANCE

Employee Information

• Name: ___________________________
• Job Title: ________________________
• Department: ______________________
• Work Location: ___________________
• Supervisor: ______________________

Provider Information

• Provider: Dr. ____________________
• Specialty: _______________________
• License #: _______________________
• Practice: _______________________
• Phone: __________________________

Date of Evaluation: //_____
Note Date: //_____

Medical Assessment
Diagnosis Summary: ____________________________________________
Date of Onset/Procedure: //_____
Current Status: □ Stable □ Improving □ Variable □ Needs monitoring

Functional Limitations

• Lifting: □ No lifting > _____ lbs
• Sitting tolerance: □ ≤ _____ minutes at a time
• Standing tolerance: □ ≤ _____ minutes at a time
• Walking tolerance: □ ≤ _____ feet/meters
• Cognitive: □ Limited multitasking □ Reduced concentration

Symptoms

• Pain Level (0–10): _____
• Fatigue: □ Mild □ Moderate □ Severe
• Other symptoms: ______________________________________________

Work Restrictions and Accommodations

• Modified duties only: □ Yes □ No
• Physical restrictions: __________________________________________
• Cognitive restrictions: ________________________________________
• Environmental restrictions: ____________________________________
• Telework: □ Allowed _____ days/week □ Not allowed
• Breaks: □ 5-min break every _____ minutes □ As needed

Phased Return-to-Work Plan
Phase 1 (Weeks 1–2)

• Hours/day: _____ | Duties: Sedentary tasks only

Phase 2 (Weeks 3–4)

• Hours/day: _____ | Duties: Add light tasks (filing, phone support)

Phase 3 (Week 5+)

• Hours/day: Full-time | Duties: Resume full job functions

Monitoring:

• Weekly review on _____ (day) by supervisor/occupational health

Legal/Policy Compliance

• ADA accommodation request submitted: □ Yes □ No
• FMLA leave used: _____ days of _____ days
• Workers’ comp form submitted: □ Yes □ No
• Company policy reference: Section _______

Employee Acknowledgment
“I understand and agree to the above phased return-to-work plan and restrictions.”
Employee Signature: ____________________ Date: //_____

Provider Certification
“I affirm the above restrictions are medically necessary and appropriate.”
Provider Signature: _____________________ Date: //_____
License #: _____________________________

Employer Approval
“I agree to implement the return-to-work plan and accommodations outlined.”
HR/Supervisor Signature: ________________ Date: //_____

This comprehensive return-to-work medical clearance template ensures systematic, medically justified reintegration planning, supports legal compliance, and facilitates employee recovery while maintaining workplace safety. By integrating phased return plans, functional restrictions, and accommodation guidelines, employers can optimize return-to-work outcomes while protecting both employees and the organization.