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Phased Return To Work Form Template

Make your employees' transition back to work smooth and effective

Adjusting back to work after a long absence can be challenging for employees and HR alike. This phased return to work form template is designed to facilitate a seamless transition, ensuring employees feel supported and ready. With this customizable form, you can improve communication, track employee progress, and validate their readiness to return, all while maintaining compliance with workplace regulations. Empower your HR team to manage returns effectively without overwhelm-try out the live template today!

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Employee full name
Employee ID
Job title
Manager or supervisor name
Work email
Type of absence
Illness or injury
Planned medical procedure
Maternity
Paternity
Parental or adoption
Bereavement
Other
Please Specify:
Absence start date
Phased return start date
Is the absence work-related?
Yes
No
Has medical clearance to return been provided?
Yes
No
Are there temporary work restrictions?
Yes
No
Describe any restrictions, capabilities, or known triggers
Tasks to avoid during the phased return
Assistive equipment or accommodations required
Ergonomic chair
Sit-stand desk
Wrist support
Screen magnifier or larger monitor
Voice-to-text software
Noise-cancelling headset
Adjustable keyboard or mouse
None
Other
Please Specify:
Proposed duration of phased return
1 week
2 weeks
3 weeks
4 weeks
6 weeks
8 weeks
Other
Please Specify:
Primary working pattern during the phase
Reduced hours each day
Fewer days per week
Light duties only
Remote work only
Combination
Other
Please Specify:
Target hours by the end of the phase (per week)
Key duties to focus on during the phase
On-site vs remote split during the phase
Fully on-site
Mostly on-site
Split 50/50
Mostly remote
Fully remote
Adjustments to be provided during the phase
Please Specify:
Controls and mitigations to implement
Has a workplace risk assessment been completed?
Yes
No
I consent to the employer sharing only the minimum necessary health information to support my return to work.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I confirm the information provided in this form is accurate to the best of my knowledge.
True
False
Employee typed signature (full name)
Employee signature date
Summary of agreed plan or required changes
Manager signature date
Manager decision on the phased return plan
Approved as proposed
Approved with changes
Not approved - more information required
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Paper art illustration depicting a phased return to work form for FormCreatorAI article.

When to use this form

This form helps HR, managers, and employees design a safe, staged path back after injury, illness, surgery, or extended leave. Use it when you need a clear plan for duties, hours, check-ins, and approvals. Example scenarios: a warehouse associate returning after a back strain, a nurse easing back after an infection, or an engineer resuming work after burnout treatment. For roles that require clinical sign-off, pair the plan with a Medical clearance form and a Medical physical exam form. If the job involves respirators or safety-sensitive tasks, reference the OSHA Respirator medical evaluation questionnaire form. The result is a time-bound schedule with milestones, agreed accommodations, and a shared record you can update as progress builds.

Must Ask Phased Return To Work Questions

  1. What work restrictions and capabilities has your licensed clinician documented, and for how long?

    This defines what you can safely do and sets a time frame for review. Attach any clinician notes or a completed Medical chart review form to ground decisions in medical evidence.

  2. What phased schedule (days per week and hours per day) can you commit to for the next 4-8 weeks?

    This sets a realistic cadence and helps managers plan coverage. Clear start and review dates make tracking and approvals simple.

  3. Which tasks should be prioritized or avoided during the first phase?

    This directs effort to high-impact, low-risk work. It guides assignment and training and lowers the chance of re-injury.

  4. What accommodations or equipment do you need to work safely?

    This surfaces needs like modified tools, remote days, or PPE. Listing them early speeds procurement and compliance.

  5. How will reduced hours affect pay, leave balances, and benefits during each phase?

    This aligns expectations on pay during reduced hours and avoids surprises. Documenting how payroll and benefits will adjust supports fair, consistent treatment.

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