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Office of Human Resources

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Return from Disability / Workers’ Compensation Form

Employee Information
Name: * Required
Employee ID: * Required
Return to Work Date: * Required

MM slash DD slash YYYY
Nursing Practice Member:
- Nursing Practice Member
Return from: * Required
Limit to
- Limit to
Restrictions
hours per day

hours per day
Movement
- Twisting
- Bending
- Limit lifting to
Hidden

Pounds

pounds
Motion
- Repetitive Motion
- Other:
additional information
Date to end Restrictions:

MM slash DD slash YYYY
Information
Reporter's email address: * Required

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