{"id":29806,"date":"2020-03-02T12:10:21","date_gmt":"2020-03-02T17:10:21","guid":{"rendered":"https:\/\/www.rochester.edu\/human-resources\/?page_id=29806"},"modified":"2026-02-20T17:05:48","modified_gmt":"2026-02-20T22:05:48","slug":"return-from-disability-workers-compensation-report","status":"publish","type":"page","link":"https:\/\/www.rochester.edu\/human-resources\/benefits\/leave-disability\/return-from-disability-workers-compensation-report\/","title":{"rendered":"Return to Work from Leaves Form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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data-form-theme='legacy' data-form-index='0' id='gform_wrapper_46' style='display:none'>\n<div class='gform_heading'>\n<p class='gform_description'>\n<\/p><\/div>\n<form method='post' enctype='multipart\/form-data'  id='gform_46'  novalidate action='\/human-resources\/wp-json\/wp\/v2\/pages\/29806' data-formid='46' novalidate>\n<div class='gform-body gform_body'>\n<ul id='gform_fields_46' class='gform_fields top_label form_sublabel_below description_below validation_below'>\n<li id=\"field_46_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\n<h2 class=\"gsection_title\">Employee Information<\/h2>\n<\/li>\n<li id=\"field_46_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label 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class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div>\n<\/li>\n<li id=\"field_46_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf-date gf-date-layout-datepicker form-control-icon\"  data-field-class=\"gf-date gf-date-layout-datepicker form-control-icon\" ><label class='gfield_label gform-field-label' for='input_46_4'>Return to Work Date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label>\n<div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_46_4_dmessage' name='input_4' id='input_46_4' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   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class='sr-only'> Required<\/span><\/span><\/span><\/label>\n<div class='ginput_container ginput_container_radio'>\n<ul class='gfield_radio' id='input_46_19'>\n<li class='gchoice gchoice_46_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Leave of Absence'  id='choice_46_19_0'    \/><br \/>\n\t\t\t\t<label for='choice_46_19_0' id='label_46_19_0' class='gform-field-label gform-field-label--type-inline'>Leave of Absence<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_46_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='Short-Term Disability'  id='choice_46_19_1'    \/><br \/>\n\t\t\t\t<label for='choice_46_19_1' id='label_46_19_1' class='gform-field-label gform-field-label--type-inline'>Short-Term Disability<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_46_19_2'>\n\t\t\t\t<input name='input_19' type='radio' value='Long-Term Disability'  id='choice_46_19_2'    \/><br \/>\n\t\t\t\t<label for='choice_46_19_2' id='label_46_19_2' class='gform-field-label gform-field-label--type-inline'>Long-Term Disability<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_46_19_3'>\n\t\t\t\t<input name='input_19' type='radio' value='Workers&#039; Compensation'  id='choice_46_19_3'    \/><br \/>\n\t\t\t\t<label for='choice_46_19_3' id='label_46_19_3' class='gform-field-label gform-field-label--type-inline'>Workers' Compensation<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_46_19_4'>\n\t\t\t\t<input name='input_19' type='radio' value='Paid Family Leave\u2013Continuous leave'  id='choice_46_19_4'    \/><br \/>\n\t\t\t\t<label for='choice_46_19_4' id='label_46_19_4' class='gform-field-label gform-field-label--type-inline'>Paid Family Leave\u2013Continuous leave<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_46_19_5'>\n\t\t\t\t<input name='input_19' type='radio' value='Family Medical Leave\u2013Continuous leave'  id='choice_46_19_5'    \/><br \/>\n\t\t\t\t<label for='choice_46_19_5' id='label_46_19_5' class='gform-field-label gform-field-label--type-inline'>Family Medical Leave\u2013Continuous leave<\/label>\n\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/fieldset>\n<\/li>\n<li id=\"field_46_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gf-checkbox\"  data-field-class=\"gf-checkbox\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Limit to<\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_46_11'>\n<li class='gchoice gchoice_46_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Limit to'  id='choice_46_11_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_46_11_1' id='label_46_11_1' class='gform-field-label gform-field-label--type-inline'>Limit to<\/label>\n\t\t\t\t\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/fieldset>\n<\/li>\n<li id=\"field_46_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\n<h2 class=\"gsection_title\">Restrictions<\/h2>\n<\/li>\n<li id=\"field_46_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gf-checkbox\"  data-field-class=\"gf-checkbox\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nursing Practice Member:<\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_46_5'>\n<li class='gchoice gchoice_46_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='Nursing Practice Member'  id='choice_46_5_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_46_5_1' id='label_46_5_1' class='gform-field-label gform-field-label--type-inline'>Nursing Practice Member<\/label>\n\t\t\t\t\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/fieldset>\n<\/li>\n<li id=\"field_46_8\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_46_8'>hours per day<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_8' id='input_46_8' type='text' value='' class='large'  aria-describedby=\"gfield_description_46_8\"    aria-invalid=\"false\"   \/><\/div>\n<div class='gfield_description' id='gfield_description_46_8'>hours per day<\/div>\n<\/li>\n<li id=\"field_46_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gf-checkbox\"  data-field-class=\"gf-checkbox\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Movement<\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_46_9'>\n<li class='gchoice gchoice_46_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Twisting'  id='choice_46_9_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_46_9_1' id='label_46_9_1' class='gform-field-label gform-field-label--type-inline'>Twisting<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice gchoice_46_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Bending'  id='choice_46_9_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_46_9_2' id='label_46_9_2' class='gform-field-label gform-field-label--type-inline'>Bending<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice gchoice_46_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Limit lifting to'  id='choice_46_9_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_46_9_3' id='label_46_9_3' class='gform-field-label gform-field-label--type-inline'>Limit lifting to<\/label>\n\t\t\t\t\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/fieldset>\n<\/li>\n<li id=\"field_46_10\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  >\n<div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div>\n<p><label class='gfield_label gform-field-label' for='input_46_10'>Pounds<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_10' id='input_46_10' type='text' value='' class='large'  aria-describedby=\"gfield_description_46_10\"    aria-invalid=\"false\"   \/><\/div>\n<div class='gfield_description' id='gfield_description_46_10'>pounds<\/div>\n<\/li>\n<li id=\"field_46_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gf-checkbox\"  data-field-class=\"gf-checkbox\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Motion<\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_46_12'>\n<li class='gchoice gchoice_46_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Repetitive Motion'  id='choice_46_12_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label 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