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Return to Work Release and Work Ability
Employee Name: __________________________________________
Return to Work
Return to work with no limitations on ________/________/__________
Return to work with limitations on _________/_________/__________ (note limitations below)
Employee’s Capabilities
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Not |
Occasio |
Freque |
Continuo |
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at |
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us |
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Lift/Carry |
all |
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No lifting |
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Push/Pull without resistance |
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> 40 lbs |
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Bend |
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Twist/turn |
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Kneel/squat |
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Sit |
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Stand/walk |
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Ladder/stair |
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climb |
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Hand, wrist, and shoulder activities |
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Avoid prolonged, repetitive, or forceful: |
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Gripping/grasping |
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Repetitive wrist |
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motion |
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Reaching |
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Above |
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shoulder |
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At shoulder |
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height |
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Below |
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shoulder |
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This treatment has been discussed with the employee.
Restrictions (circle) |
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Keyboarding / hrs |
0 |
1 - 2 |
3 – 4 |
5 – 6 |
7+ |
Writing / hrs |
0 |
1 - 2 |
3 – 4 |
5 – 6 |
7+ |
Change positions every:
As needed
Half hour
One hour
Two hours
Worksite stretches
Exercises
Other
Comments:
_________________________________________________ |
__________________________ |
Physician Signature |
Date |
Important Facts about Work Release
What is a Work Release form?
A Work Release form is a document that allows individuals, often those who are incarcerated or under supervision, to leave their place of confinement for employment purposes. This form serves as a legal permission slip, ensuring that the individual can work while still adhering to the terms of their supervision or incarceration.
Who is eligible to use a Work Release form?
Eligibility for a Work Release form typically includes individuals who are currently incarcerated or on probation. Specific criteria may vary by jurisdiction, but generally, the following factors are considered:
- Type of offense
- Behavior while incarcerated
- Employment opportunities available
- Support from a potential employer
How do I apply for a Work Release form?
To apply for a Work Release form, you should follow these steps:
- Contact your supervising officer or the facility where you are housed.
- Obtain the necessary application form, which may be available online or in person.
- Complete the application, providing all required information, including job details.
- Submit the application for review and await approval.
What information is required on the Work Release form?
The Work Release form usually requires the following information:
- Your personal details (name, address, etc.)
- Details of the employer (name, address, contact information)
- Job title and description
- Work schedule (days and hours)
- Reason for requesting work release
What happens if my Work Release application is denied?
If your application for a Work Release is denied, you will typically receive a written explanation detailing the reasons for the denial. You may have the option to appeal the decision or reapply after addressing the concerns raised in the denial.
Can I work anywhere with a Work Release form?
Generally, you cannot work just anywhere. The employer must be approved by the supervising authority. It is important to ensure that the job does not pose a risk to public safety or violate the terms of your supervision.
What are the responsibilities of the employer in a Work Release program?
Employers participating in a Work Release program have specific responsibilities, including:
- Ensuring a safe work environment
- Reporting any violations of the Work Release terms to the supervising authority
- Maintaining communication with the individual’s supervising officer
How does a Work Release affect my supervision status?
Participating in a Work Release program can positively impact your supervision status. Successful completion of work release may demonstrate your commitment to rehabilitation and could lead to reduced supervision or early release. However, any violations during this period could result in stricter supervision or additional penalties.
Key takeaways
When filling out and using the Work Release form, there are several important points to consider. Here are five key takeaways:
- Accuracy is Essential: Ensure that all information provided on the form is correct. Mistakes can lead to delays or complications in processing your request.
- Understand the Purpose: The Work Release form is designed to allow individuals to leave a correctional facility for employment opportunities. Familiarize yourself with its intended use to maximize its benefits.
- Complete All Sections: Every section of the form must be filled out thoroughly. Incomplete forms may be rejected, prolonging your ability to work outside the facility.
- Submit on Time: Be aware of deadlines for submitting the Work Release form. Late submissions can result in missed opportunities for employment.
- Follow Up: After submission, it’s wise to check on the status of your application. This ensures that there are no outstanding issues that could hinder your work release.