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Release To Return To Work Form. This is a Oregon form and can be use in Medical Workers Comp.
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Tags: Release To Return To Work, 3245, Oregon Workers Comp, Medical
Return form to:
RELEASE TO RETURN TO WORK
Claim number
Name of worker
Please fill out this form and return it to us at the address indicated above.
1. Is the worker medically stationary?
Yes
No
If yes, date:
If no, estimated medically stationary date:
(Provide closing information and complete Form 827.)
Are there permanent restrictions?
Yes
No
Unknown
Next scheduled appointment date:
2. Worker is released to:
full duty without limitations
modified duty
Date:
(Do not complete lines 3 through 11. Sign below.)
from (date):
through (date):
(specify limitations below)
through (date):
modified hours
specify hours:
from (date):
not released to work
Est. RTW date:
If modified release, provide date of anticipated regular release:
Hours:
3. In a/an
8
10 12
other
worker can stand/walk a total of
4. At one time, worker can stand/walk
5. In a/an
8
10
12
other
worker can sit a total of
6. At one time, worker can sit
No limitations
1
2
3
4
5
6
7
8
80
85
90
Other (specify)
-hour workday,
-hour workday,
7. The worker is released to return to work in the following range for lifting, carrying, pushing/pulling:
Pounds
100
Occasionally
Frequently
10. Worker is able to:
Continuous
67-100% of the day
a. Stoop/bend -----------------b. Crouch ----------------------c. Crawl------------------------d. Kneel ------------------------e. Twist ------------------------f. Climb------------------------g. Balance ---------------------h. Reach------------------------i. Push/pull---------------------
Frequently
34-66% of the day
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Occasionally
6-33% of the day
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Dominant hand
Right
Left
No
Intermittently
1-5% of the day
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Not at all
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11. Other functional limitations or modifications necessary in worker’s employment:
Signature of medical service provider
∗
Additional comments may be written on back of form.
Printed name
Date
440-3245 (10/05/DCBS/WCD/WEB)
∗
See OAR 436-010-0210 regarding who may provide medical services and authorize time loss.
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