Work Restrictions/Return-to-Work Note

Date Issued: [Date]

Clinic/Organization: [Clinic/Organization Name, Address, Phone, Fax]

Provider: [Provider Name, Credentials], NPI: [NPI]

Patient Information

Patient Name: [Full Name]

Date of Birth: [DOB]

(Include the following fields only if workers' compensation or occupational injury context applies; otherwise omit entirely.)

Employer: [Employer Name]

Job Title: [Job Title] ([patient-reported / employer-provided])

Claim Number: [Claim #]

Date of Injury: [Date]

Condition

[Brief statement of condition necessitating restrictions, including laterality/body region when relevant] (1–2 lines only; do not include detailed history, imaging narratives, medication lists, or unrelated diagnoses.)

Work-relatedness: [Work-related / Non-work-related / Unknown]

[Brief objective finding supporting restrictions, e.g., ROM limitation, wound status, post-op protocol] (Include only if restrictions are substantial or for workers' compensation purposes; otherwise omit.)

Work Status

Status: [Full Duty / Modified Duty / Off Work / Graduated Return-to-Work]

Effective Date: [Date] Through: [Date or "through re-evaluation on (date)"]

[Phased plan with dates for each phase, listed chronologically with no date gaps] (Include only if graduated return-to-work or multiple phases apply.)

[Statement of information limitations, e.g., job demands unknown or no recent exam] (Include only if applicable; do not guess at restrictions without adequate information.)

Functional Restrictions

(Include this section only when Work Status is Modified Duty or Graduated Return-to-Work. Use specific, measurable limits. Avoid vague terms like "light duty" unless paired with specific limits.)

Lifting/Carrying/Push-Pull: [Weight limits with frequency, e.g., "Lift/carry up to 10 lb occasionally, 5 lb frequently; push/pull up to 15 lb"]

Postural Limits: [Bending, twisting, kneeling, squatting, climbing, overhead reaching restrictions with frequency or duration limits as applicable]

Upper Extremity: [Side affected; grip/pinch limits; repetitive motion limits; keyboard/fine motor tolerances] (Include only if upper extremity restrictions apply.)

Position Tolerance: [Sitting, standing, walking tolerances with durations and break frequency, e.g., "Sit up to 30 min at a time, stand/walk up to 20 min; change position every 30 min"]

Safety-Sensitive Restrictions: [Driving, machinery operation, work at heights, tasks requiring rapid reaction] (Note if medication-related. Include only if safety-sensitive restrictions apply.)

Environmental: [Temperature, vibration, chemical, noise exposures to avoid; required PPE or assistive devices] (Include only if environmental restrictions apply.)

Schedule Limits: [Hours per day, days per week, shift restrictions, mandatory rest breaks] (Include only if schedule restrictions apply.)

Permissible Tasks: [Affirmative "can do" statements describing tasks the worker may safely perform within restrictions] (Include when modified duty placement is the goal.)

[Job description not available; restrictions reflect general functional capacity.] (Include if employer job description was not provided.)

Follow-up

Next Follow-up: [Date or "not yet scheduled"]

[Requirements before restrictions can be extended, e.g., re-examination, job description, post-op protocol clearance] (Include if follow-up not yet scheduled.)

Reassess Earlier If: [Triggers for earlier reassessment, e.g., worsening symptoms, inability to perform modified duty safely]

Provider Attestation

This opinion is based on the evaluation described above and may change with clinical reassessment.

Signature: _______________________________

Printed Name, Credentials: [Provider Name, Credentials]

Date Signed: [Date]