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Return-to-Work Note Template
A return-to-work note tells an employer whether your patient can go back to work, from when, and with what limits. Describe what they can and can’t do, and for how long, so the employer can plan the work. Leave the diagnosis out unless the patient agrees.
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- Word and text downloads
- Two filled examples
Blank return-to-work note template
FreeRETURN-TO-WORK NOTE [Clinic name] [Address] [Phone] Date: [Date of note] To: [Employer name, or To whom it may concern] Attention: [Manager, human resources, or occupational health contact, if known] Re: [Patient's full name] Date of birth: [Date] Job title: [Job title] Reference: [Employee or claim number, if the employer asked for one] Date of assessment: [Date you saw the patient] [Patient name] asked me for this note and agreed to the information in it. FITNESS FOR WORK Decision: [Fit for full duties, fit for modified duties with the restrictions below, or not yet fit for work] Effective from: [Date the decision takes effect] Until: [End date of the restrictions, or the review date below] RESTRICTIONS Lifting and carrying: [Limit and how often, e.g. no lifting over 10 kg / 22 lb] Bending, twisting, and reaching: [What to avoid or limit, e.g. no repeated bending] Sitting, standing, and walking: [Limits, e.g. change position every 30 minutes] Hours and breaks: [Hours per shift, days per week, and extra breaks] Use of a hand, arm, or leg: [Which side, and what to avoid, e.g. no gripping tools with the right hand] Ladders and heights: [e.g. no ladders or work at heights] Driving and machinery: [Whether the patient can drive for work or operate machinery] Other: [Any other limit, e.g. no overtime or night shifts] How long each lasts: [Duration of each restriction, if they differ] ESSENTIAL DUTIES [If the employer listed the job's essential duties: whether the patient can do each one, with or without the restrictions above] GRADUAL RETURN [Hours and tasks week by week, e.g. week 1: 4 hours a day, 3 days; or not needed] REVIEW Review date: [When you will reassess and update this note] Questions: [Phone or email for questions about the restrictions] Sincerely, [Your name, credentials] [License or registration number] [Signature]
Use it for
- Return after sick leave
- Light or modified duties
- Fitness-for-duty requests
- Graded return after time off
- Work restrictions after an injury
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Return-to-work note: modified duties after a back strain
Family physician to employer, warehouse order picker
Patient and employer
Note for a 38-year-old order picker at a distribution warehouse, to give to his shift supervisor. Assessed October 23, 2026. He asked for the note and agreed to its contents.
Fitness decision
Fit for modified duties from October 27, 2026, with the restrictions below, for 2 weeks. Full duties are expected after the review on November 9 if he continues to improve.
Restrictions
For 2 weeks: no lifting over 10 kg / 22 lb. No repeated bending or twisting at the waist. Change position at least every 30 minutes, between standing, sitting, and walking. No ladders.
Hours
Week 1: 6-hour shifts. Week 2: full shifts, with the same restrictions.
Essential duties
No list of duties was provided. From his description of the job, he can scan, label, and pick light items, and check stock. He should not lift full cases or load trucks until the review.
Medical details
He asked me to say that this is a back injury, so his supervisor understands the restrictions. No other medical details are included.
Review
Review on November 9, 2026. I will give him an updated note after that visit.
Return-to-work note: graded return after medical leave
Family physician to employer, after 6 weeks off for depression; diagnosis not shared
Patient and employer
Note for a 34-year-old payroll administrator, to give to human resources. Assessed October 22, 2026. She asked that no medical details be shared, and agreed to the rest of the note.
Fitness decision
Fit for a graded return to her usual role from October 26, 2026, on the schedule below.
Gradual return
Week 1: 4 hours a day, 3 days. Week 2: 4 hours a day, 5 days. Week 3: 6 hours a day, 5 days. Week 4: full hours, if the review supports it.
Restrictions
A short break of about 10 minutes every 2 hours. Daytime hours only, with no overtime, until full hours. Time off for one appointment a week, about 1 hour.
Essential duties
Human resources listed 4 duties. Processing payroll: yes. Answering staff questions by phone and email: yes. Month-end reports: yes, from week 3. Training new staff: not before the review.
Medical details
Not included, at her request. The schedule and restrictions above are what the employer needs to plan her return.
Review
Review on November 6, 2026, at the end of week 2. I will give her an updated note with any changes to the schedule.
What goes in each part.
Patient and employer
Who the note is about, who it goes to, and that the patient agreed to it.
- The patient’s name and date of birth
- The employer, and a contact if the patient gave you one
- The job title, and any employee or claim number the employer asked for
- The date you assessed the patient
- That the patient asked for the note and agreed to what it says
Avoid: Sending the note to the employer without the patient’s consent. Give it to the patient unless they have agreed you send it directly.
Fitness decision
One clear answer, and the date it takes effect.
- Fit for full duties, fit for modified duties, or not yet fit for work
- The date the decision takes effect
- When the restrictions end, or when you will review them
Avoid: “May return to work as tolerated” with no date or limits. The employer can’t plan the work from it.
Restrictions
What the patient can and can’t do, in terms a supervisor can act on.
- Lifting limits in kg and lb, and how often
- Sitting, standing, and walking limits, and how often to change position
- Hours per shift, days per week, and breaks
- Driving, machinery, ladders, and heights
- Use of a hand, arm, or leg, and which side
- How long each restriction lasts
Avoid: “Light duty” or “no strenuous work” on its own. Say how much, how often, and for how long.
Essential duties
If the employer sent a list of the job’s essential duties, answer for each one. If not, this part can go.
- Each listed duty, and whether the patient can do it now, with or without the restrictions
- Duties they can’t do yet, and when you expect to review them
Avoid: Answering a list of duties with one line saying “fit to return.” Address each duty the employer listed.
Gradual return
A schedule that builds up hours or tasks over a set number of weeks, when a full return at once isn’t realistic.
- Hours and days for each week
- Which tasks come back, and when
- Breaks, and time for treatment appointments if needed
- When the schedule ends, or the review that decides the next step
Avoid: An open-ended schedule. Give an end date or a review date.
Review and your details
When the restrictions will be looked at again, and how the employer can reach you.
- The review date
- A contact for questions about the restrictions
- Your name, credentials, and license or registration number
- Your signature, and the date
Common mistakes, and how to avoid them.
Including the diagnosis without consent
The employer usually needs to know whether the patient can do the job, the limits, and how long they last, not the diagnosis. Include it only if the patient agrees.
“Light duty” with no detail
Give numbers: the weight, the hours, how often to change position. A supervisor can’t act on “light duty.”
No end date or review date
Without one, the employer doesn’t know when to expect a full return. Set a date for each restriction, or a review.
Designing the job
Describe the limits; the employer decides how to accommodate them. You can suggest an option, but naming a specific role goes beyond what you assessed.
Ignoring the employer’s form or duty list
If an employer, insurer, or compensation board sent its own form or a list of duties, complete that. A separate letter may not be accepted in its place.
Clearing what you didn’t assess
For safety-sensitive work, such as driving or operating machinery, say what you assessed. If you can’t judge it, say so, and suggest a fitness-for-duty or functional assessment.
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Frequently asked questions.
What should a return-to-work note include?
Whether the patient can return to full duties, modified duties, or not yet; the date that takes effect; each restriction in functional terms and how long it lasts; a gradual schedule, if any; a review date; and your name, credentials, license or registration number, and signature.
Does a return-to-work note need the diagnosis?
Usually not. An employer is generally entitled to know whether the person can do the job, any limits, and how long they last, not the diagnosis. Include it only if the patient agrees.
How do you write a light duty note?
Replace “light duty” with specific limits: the most the patient can lift in kg and lb, how long they can sit or stand, hours per shift, and what to avoid, such as ladders or driving. Give an end date or a review date.
What is a fitness-for-duty letter?
A note confirming that an employee can return to their job, often requested after medical leave. If the employer sent a list of the job’s essential duties, say whether the patient can do each one.
Who decides what modified work the patient does?
The employer. You describe what the patient can and can’t do, and for how long; the employer decides how to accommodate it, and may ask you to clarify the limits, with the patient’s consent.
What if an insurer or compensation board sends its own form?
Complete their form. Insurers and workers’ compensation boards often have their own functional abilities forms, and the same facts go there: abilities, restrictions, and how long they last.
Show all questions
How long should work restrictions last?
As long as you expect them to be needed, with a review booked before they end. If the patient recovers sooner, a new note can lift them early.
Is this return-to-work note template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
Can Vero write a return-to-work note from my visit?
Yes. Vero drafts the note from your visit in your template, with the restrictions you discussed. Review and edit it, then export it to PDF or Word, print it, or email it.
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For pumping or breastfeeding at work: the breaks, the space, any medical reason, and an end date.
Medical forms library
Functional abilities, disability, and workers’ compensation forms, with official links.
Vero Documents
Fill employer, insurer, and compensation board forms from the visit and the chart.
Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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