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Medical Return To Work Form
"I need a Medical Return to Work Form for our manufacturing company that complies with New Zealand safety regulations, specifically for employees returning from surgery with potential physical restrictions and requirements for graduated return arrangements."
1. Employee Information: Basic details including name, position, department, and employee ID
2. Medical Provider Information: Details of the treating healthcare provider including name, qualification, and contact information
3. Absence Information: Dates of absence, reason for medical leave, and whether condition is work-related
4. Work Capacity Assessment: Current medical status and overall capacity to return to work
5. Work Restrictions: Specific limitations or modifications required for safe return to work
6. Return to Work Timeline: Proposed date and format of return (full-time, partial, graduated)
7. Authorization and Signatures: Required signatures from employee, medical provider, and employer representative
1. ACC Claim Details: Required when the medical condition is related to a workplace injury or illness covered by ACC
2. Rehabilitation Plan: Needed for complex cases requiring a structured return to work program
3. Workplace Modifications: Required when specific workplace adjustments or equipment are needed
4. Follow-up Schedule: Include when ongoing medical review is required
5. Mental Health Considerations: Required when return to work involves mental health conditions requiring specific accommodations
1. Schedule A - Physical Restrictions Guide: Detailed checklist of physical activities and associated restrictions
2. Schedule B - Graduated Return to Work Plan: Detailed week-by-week plan for increasing work hours or duties
3. Schedule C - Workplace Modification Requirements: Specific details of required workplace adjustments or equipment
4. Appendix 1 - Privacy Statement: Statement regarding the handling and protection of medical information
5. Appendix 2 - Employee Rights and Responsibilities: Summary of employee's rights and obligations during return to work process
Authors
Healthcare
Manufacturing
Construction
Professional Services
Retail
Education
Government
Technology
Transportation
Hospitality
Mining
Agriculture
Financial Services
Human Resources
Health and Safety
Occupational Health
People and Culture
Risk Management
Operations
Employee Relations
Wellness and Benefits
Medical Services
Compliance
HR Manager
Health and Safety Manager
Occupational Health Nurse
Return to Work Coordinator
HR Business Partner
People and Culture Manager
Workplace Health Advisor
Employee Relations Manager
Risk Manager
Operations Manager
Line Manager
Department Supervisor
Rehabilitation Coordinator
Wellness Coordinator
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