Connecticut's Workers' Compensation Commission lists this one-page form for attending providers to report an injured employee's work status after a visit. The provider marks regular duty, return with or without restrictions, or temporary total disability, sets hour limits in an 8-hour day for standing, walking, sitting and other activities, adds lifting and hand or foot restrictions, diagnosis and treatment plan.
The attending physician or office completes and signs it. The employee signs to acknowledge receiving a copy.
Download the current version from the source each time; forms change without notice.
Workers' Compensation - Employee Medical & Work Status Form
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The form says to fax a copy to the carrier, TPA, employer or designee within one business day of the visit. A copy is also given to the employee at the visit and another is filed in the medical record.
Yes, for the restriction portion. A provider who completed the employer's work status form, or discussed restrictions by phone with the employer's representative, need not complete the restrictions here. Release to full duty or total disability must still be documented on this form or the employer's standard form.
For an 8-hour workday the provider checks 1 to 2, 2 to 4, 4 to 6, 6 to 8 hours or none for standing, walking, sitting, bending, climbing, reaching, twisting, crawling, driving and use of feet and hands, plus a lifting limit and right, left or both for repetitive hand and foot use.