RETURN-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]