The Medical Return to Work Form is a crucial document used across New Zealand workplaces to manage the safe and effective return of employees following medical leave. This form is required whenever an employee needs to return to work after a significant illness, injury, or medical procedure, ensuring compliance with the Health and Safety at Work Act 2015 and related legislation. It captures critical information from healthcare providers about an employee's work capacity, necessary restrictions, and accommodation requirements. The form serves as a legal record of medical clearance and helps employers fulfill their duty of care obligations while protecting employee privacy under New Zealand law. It is particularly important for cases involving ACC claims, graduated return-to-work programs, or when workplace modifications are needed.
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1. Employee Information: Basic details including name, position, department, and employee ID
2. Medical Provider Information: Details of the treating healthcare provider including name, qualification, and contact information
3. Absence Information: Dates of absence, reason for medical leave, and whether condition is work-related
4. Work Capacity Assessment: Current medical status and overall capacity to return to work
5. Work Restrictions: Specific limitations or modifications required for safe return to work
6. Return to Work Timeline: Proposed date and format of return (full-time, partial, graduated)
7. Authorization and Signatures: Required signatures from employee, medical provider, and employer representative
1. ACC Claim Details: Required when the medical condition is related to a workplace injury or illness covered by ACC
2. Rehabilitation Plan: Needed for complex cases requiring a structured return to work program
3. Workplace Modifications: Required when specific workplace adjustments or equipment are needed
4. Follow-up Schedule: Include when ongoing medical review is required
5. Mental Health Considerations: Required when return to work involves mental health conditions requiring specific accommodations
1. Schedule A - Physical Restrictions Guide: Detailed checklist of physical activities and associated restrictions
2. Schedule B - Graduated Return to Work Plan: Detailed week-by-week plan for increasing work hours or duties
3. Schedule C - Workplace Modification Requirements: Specific details of required workplace adjustments or equipment
4. Appendix 1 - Privacy Statement: Statement regarding the handling and protection of medical information
5. Appendix 2 - Employee Rights and Responsibilities: Summary of employee's rights and obligations during return to work process
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