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The Return To Work Medical Form is a crucial document used when employees need to resume work after medical absence, whether due to illness, injury, or other health-related circumstances. This form, designed to meet U.S. federal and state requirements, provides essential documentation of medical clearance while protecting both employer and employee interests. It includes medical provider certification, specific work capabilities and restrictions, required accommodations, and ensures compliance with ADA, FMLA, HIPAA, and other relevant legislation. The form helps organizations manage risk while supporting safe and appropriate return-to-work transitions.

1. Employee Information: Basic identifying information about the employee including name, ID, department, and position

2. Medical Provider Information: Details of the healthcare provider making the assessment including name, credentials, contact information

3. Work Status Evaluation: Assessment of employee's ability to return to work, including date of return and capacity to work

4. Work Restrictions: Detailed description of specific limitations or modifications needed for safe return to work

5. Duration: Timeframe for restrictions or accommodations, including review/reassessment dates