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Date Returned to Work: Number of working days absent: Are you: full time / part time *. *Delete as appropriate. State briefly why you were unfit for work (specify Return to Work Information Template - This template will help employers provide all workers with return to work information as required under the Accident Return To Work Medical Evaluation Form. Employee's Name: ID#. Date of injury/surgery/onset or onset of illness: //___ Date of Exam: ______. Diagnosis or Return to Work Interview Record Form. This Return to Work Interview Form is designed as a guide for the line manager when meeting with employees on their Managing Sickness Absence - Return to Work Form (Example) This form must be completed and signed by all members of staff following eachepisode of sic To help you prepare, you can print the necessary forms in advance and have them packaged along with Sample Return to Work Plan Monitoring Form. PHYSICIAN'S RELEASE TO RETURN TO WORK FORM. Employee's Name: Date: Physician's Name: Telephone #:. To be completed by Physician. 21 Jul 2011 Sample - Completed Return to Work Arrangements - Demonstrates a completed Return to Work Arrangements form. These return to work arrangements are for: . If there is any additional information you wish to include in this form, please attach any supporting documentation
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