Release To Return To Work {3245}

Return form to: RELEASE TO RETURN TO WORK Name of worker Claim number Please fill out this form and return it to us at the address indicated above. 1. Is the worker medically stationary? If no, estimated medically stationary date: Next scheduled appointment date: 2. Worker is released to: full duty without limitations modified duty modified hours not released to work Yes No If yes, date: (Provide closing information and complete Form 827.) Are there permanent restrictions? Yes No Unknown Date: (Do not complete lines 3 through 11. Sign below.) from (date): specify hours: Est. RTW date: Hours: through (date): from (date): (specify limitations below) through (date): If modified release, provide date of anticipated regular release: No limitations 1 2 3 4 5 6 7 8 Other (specify) 3. In a/an 8 10 12 other worker can stand/walk a total of 4. At one time, worker can stand/walk 5. In a/an 8 10 12 other worker can sit a total of 6. At one time, worker can sit Pounds Occasionally Frequently <10 10 15 20 25 -hour workday, -hour workday, 7. The worker is released to return to work in the following range for lifting, carrying, pushing/pulling: 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 >100 8. Worker can use hands for repetitive: Right Left Yes No Yes a. Fine manipulation Yes No Yes b. Pushing and pulling Yes No Yes c. Simple grasping Yes No Yes d. Keyboarding 9. Worker can use feet for repetitive raising and pushing (as in operating foot controls): 10. Worker is able to: Continuous 67-100% of the day Frequently 34-66% of the day Occasionally 6-33% of the day No No No No Yes Dominant hand Right Left No Intermittently 1-5% of the day Not at all a. Stoop/bend -----------------b. Crouch ----------------------c. Crawl------------------------d. Kneel ------------------------e. Twist ------------------------f. Climb------------------------g. Balance ---------------------h. Reach------------------------i. Push/pull--------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 11. Other functional limitations or modifications necessary in worker's employment: Signature of medical service provider 440-3245 (10/05/DCBS/WCD/WEB) Additional comments may be written on back of form. Printed name Date See OAR 436-010-0210 regarding who may provide medical services and authorize time loss. American LegalNet, Inc. www.USCourtForms.com