Work/School Activity Restrictions and Modified Duty Letter

[Organization name or clinic letterhead]
[Street address]
[City, State ZIP]
[Phone] • [Fax]

[Date of letter]

[Recipient name and title / To Whom It May Concern]
[Organization name]
[Address]

Re: Work/School Activity Restrictions — [Patient full name], DOB: [Date of birth]

This letter is provided at the request of the [patient / parent or legal guardian] and communicates functional capacity and activity restrictions only. [Patient name] [was evaluated on / is currently under my care as of] [date]. (Do not include diagnosis, treatment details, or clinical rationale unless explicitly requested by the patient and necessary for the administrative purpose.)

Current Status

Status: [Excused from work/school / Return to full duty / Return to modified duty with restrictions / May attend school but excused from specific activities]
Effective: [Start date] through [end date / reevaluation on date]

Activity Restrictions

(List only applicable, function-based restrictions using quantified, measurable limits. Omit domains that do not apply. If this letter serves solely as an absence excuse with no restrictions, omit this section entirely.)

[Relevant activity restrictions with specific limits, e.g., lifting max 10 lb, no standing >30 minutes continuously, no overhead reaching, excused from PE/athletics, elevator access required] (Use quantified terms—weight in pounds, duration in minutes/hours, frequency per shift. Avoid vague language like "light duty" or "no heavy lifting" without definitions. Include allowed activities if helpful for placement.)

Accommodations: [Relevant accommodation suggestions if applicable, e.g., ergonomic workstation, sit-stand option, reduced hours, rest breaks, testing accommodations] (Include only if clinically indicated; omit if none recommended.)

(If job or school activity demands are unknown, note: A job functions list or activity description can be provided for refinement of restrictions.)

Duration & Follow-up

Restrictions effective [start date] through [end date / reevaluation on date]. [Follow-up scheduled on date / Follow-up recommended on or before date]. Earlier reevaluation advised if condition worsens. Restrictions are based on current clinical assessment and may change upon reevaluation. The employer or school determines whether accommodations can be provided consistent with operational requirements.

Sincerely,

[Clinician full name], [Credentials]
[Organization name]
[Phone/Fax for administrative follow-up]
[Signature]
Date Signed: [Date]