Instructions: Edit any information below and click "Export Word" to generate the document.
[[formData.formTitle]]
Restricted Duty Job Description
Descripción del trabajo restringido
| Employee Name: | Date: | ||
|---|---|---|---|
| Employer: | [[formData.claimField]]: | ||
| Nonprofit Organization: | Job Title: | ||
| Associate #: | |||
| Employee's Current Restrictions: | |||
| Job Duties: | |||
TO BE COMPLETED BY AUTHORIZED TREATNG PHYSICIAN:
__________ I do release the employee to the job described
__________ I do not release the employee to the job described
__________ I release the employee to the job described with the additional following restrictions/limitations/modifications:
| Physician Name | Physician Signature | Date |