Return-to-Work Plan Template

Introduction

• Purpose: This template is designed to help employers create individualized RTW plans for employees returning to work after an injury or illness.

• Objective: To facilitate a safe, effective, and accommodating return-to- work process tailored to each employee’s specific needs.

Employee Information

• Name:

• Position:

• Department:

• Date of Injury/Illness:

• Date of RTW Plan Creation:

Medical Assessment Summary

• Summary of Injury/Illness:

• Current Functional Abilities:

• Restrictions or Limitations:

• Anticipated Duration of Restrictions:

Return-to-Work Goals

• Short-Term Goals:

• Long-Term Goals:

• Expected Outcomes of RTW Plan:

Phased Return-to-Work Schedule

• Phase 1:

  • Start Date:

  • Modified Duties:

  • Working Hours:

  • Duration:

• Phase 2:

  • (Repeat as necessary for additional phases)

Workplace Accommodations

• Physical Accommodations:

• Ergonomic Adjustments:

• Schedule Modifications:

• Other Necessary Accommodations:

Support and Monitoring

• Assigned RTW Coordinator/Contact:

• Support Services or Resources Provided:

• Monitoring and Review Schedule:

• Communication Plan with Employee:

Employee Acknowledgment

• Employee’s Acknowledgment of Plan:

• Employee’s Signature:

• Date:

Employer Acknowledgment

• Employer’s Approval of Plan:

• Supervisor/Manager’s Signature:

• Date:

Review and Adjustment

• Scheduled Review Dates:

• Procedure for Adjusting Plan:

Conclusion:

A statement emphasizing the commitment to a successful and supportive return-to-work process.