Form 110 RELEASE TO RETURN TO WORK PLEASE PRINT OR TYPE Instructions: This form must be completed by the adjuster after receiving a physician notification of release to return to full or light duty work. The form must be submitted to the Labor Commission and to the injured worker within five (5) days of the release date. General Information Worker Name Address Phone Number Injury Date Employer Actual # of Lost Work Days SS# Released to Regular Duty Released to Light Duty Date Permanent Impairments, if any: Date Permanent Impairments, if any: Anticipated Date of Release to Regular Duty: Name of Person Submitting Form Carrier Name Phone Number Official Form 110 Date Submitted Revised 05/16 State of Utah * Labor Commission * Division of Industrial Accidents 160 East 300 South * P.O. Box 146610 Salt Lake City, UT 84114-6610 * Telephone: 801530-6800 * Fax: 801-530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com