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Physician Release to Return to Work Form Template

Streamline employee return with our release form template

Getting back to work after an illness or injury can be complicated, especially when it comes to navigating doctor paperwork. This Physician Release to Return to Work form template is designed for employers, HR professionals, and healthcare providers looking to ensure a smooth transition back to the workplace. You'll streamline communication, verify employee fitness, and maintain compliance with clear documentation, all while saving time on paperwork. Plus, it's WCAG-aligned for accessibility. Explore the live template today.

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Employee full name
Employee job title
Employee ID (if applicable)
Company or employer name
Department or work location
Supervisor name
Supervisor phone
Supervisor email
Date of injury or illness
Primary diagnosis or condition
Is this condition work-related?
Yes
No
Unsure
Was hospitalization or surgery required?
Yes
No
Is the condition currently contagious?
Yes
No
Unsure
Medications and any work-safety considerations
Date of most recent evaluation
Are any prescribed medications likely to impair work safety?
Yes
No
Unknown/Not applicable
Release status
Cleared for full duty (no restrictions)
Cleared for work with temporary restrictions
Not cleared to return to work
Effective date of this release
Work schedule permitted
Full time
Part time
Modified duty
Telework/remote work
No work
Not applicable
Maximum hours per day
Up to 2 hours
Up to 4 hours
Up to 6 hours
Up to 8 hours
Up to 10 hours
Up to 12 hours
No limit
Not applicable
Maximum consecutive days per week
Anticipated date for return to full duty
Follow-up appointment date
Follow-up or re-evaluation required
Yes
No
Lifting or carrying limit
No lifting
Up to 5 lb
Up to 10 lb
Up to 20 lb
Up to 30 lb
Up to 50 lb
No restriction
Not applicable
Allowed sitting per shift
No sitting
Up to 1 hour
Up to 2 hours
Up to 4 hours
Up to 6 hours
Full shift as tolerated
Not applicable
Allowed standing or walking per shift
No standing/walking
Up to 1 hour
Up to 2 hours
Up to 4 hours
Up to 6 hours
Full shift as tolerated
Not applicable
Activities to avoid
Please Specify:
Other activity restrictions
Required rest or break frequency
No special breaks
5 minutes each hour
10 minutes each hour
15 minutes every 2 hours
As needed
Not applicable
Assistive devices required
Brace or splint
Cane
Crutches
Sling
Walking boot
Wheelchair
None
Other
Please Specify:
Other assistive devices
Other PPE details
Essential job tasks the employee can perform
Essential job tasks the employee should not perform
Recommended workplace accommodations
Personal protective equipment (PPE) required
Gloves
Mask or respirator
Eye protection
Hearing protection
Steel-toe footwear
Hard hat
None
Other
Please Specify:
Best contact person for accommodations
Contact phone
Contact email
Physician full name
Clinic or practice name
License number and state
Physician phone
Physician email
Clinic address
Physician signature (type full name)
Date signed
I certify that this release reflects my best medical judgment
Yes
No
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Paper art illustration depicting a physician release to return to work form for medical use.

When to use this form

Use this form when an employee is coming back after injury, surgery, illness, or parental leave. It lets a physician confirm fitness for duty, set a return date, and note any work restrictions. You get clear documentation for HR, safety, and payroll, and the employee gets a safe, smooth transition. It is useful for desk roles and physically demanding jobs, including healthcare, warehouse, and field work. Pair it with the Medical questionnaire form to capture history and symptoms, then finalize duties with the Return to work discussion form. The result is a compliant release that helps you assign tasks, schedule hours, and reduce risk.

Must Ask Physician Release to Return to Work Questions

  1. What date are you medically cleared to return to work, and is this full duty or with restrictions?

    This sets a firm start date and clarifies whether you should schedule regular hours or modified duty. It reduces back-and-forth and prevents scheduling errors.

  2. What specific restrictions, limitations, or accommodations are required, and for how long?

    Details like lifting limits, standing time, or exposure risks help you tailor tasks and PPE. Clear time frames guide managers on rechecks and temporary assignments.

  3. Which essential job functions can the employee perform safely today?

    Mapping abilities to core duties supports compliant decisions and reduces injury risk. It also documents why certain tasks are reassigned.

  4. What medications, treatments, or side effects could impact safety or performance?

    Noting drowsiness, dizziness, or infection risk helps set safe schedules and duties. Keep these notes with your Medical chart review form to maintain a consistent record.

  5. Is the condition infectious, and are any clearance tests required?

    This protects coworkers and customers by confirming non-contagious status. For respiratory risks, use the TB Screening form to align with workplace policy.

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