Samples of

By Elizabeth Morales,2014-06-17 18:08
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Samples of ...

Sample Return to Work Plans

Please note that this is a sample to guide discussion and the development of a tailored

return to work plan for an individual employee. It is not intended to address all situations.


A return to work plan lays out the steps that need to be taken to return and employee

    to his or her pre-injury job.

In the ideal situation, the plan is developed jointly by the injured employee, the

    employee’s supervisor, and if applicable the return to work co-ordinator (the person

    who co-ordinates the process), the worker’s health care provider (through the provision of functional abilities information) and the union representative, (if

    applicable). Supervisors from other areas, the company’s medical department, or

    staff from the WSIB can assist in the process when the need arises. A return to work

    plan includes the following:


    These goals set out milestones for the worker to achieve until he or she

    reaches the final goal: a return to pre-injury employment.


    This includes the responsibilities of the worker, the supervisor or manager,

    and any co-workers who will be assisting the worker.


    These will provide a yardstick to measure the employee’s progress. It is

    important that the plan has a beginning and an end, as graduated work is a

    means to achieve a return to pre-injury work, and is not an end in itself.

    Make sure to include a clear definition of what is considered progress (for

    example, the employee can work five hours a day by week three, or the

    worker can assume tasks by week five).


    If, for example, the worker is going to attend health or medical

    appointments during work hours, these visits must be co-ordinated with the

    requirements of the proposed return to work plan. Staff that will be

    impacted by these health care needs will also need to be advised (with the

    worker’s permission).

The following pages contain examples of the kinds of formats you can develop for

    your return to work plans.

SAMPLE: Return to Work Case Plan Discussion Guide

    Disclosure of personal information, including medical, is at the discretion of the employee. Possible topics to discuss / relevant to completing the case plan.

    Health Recovery (identify current health status).

    ? Areas of injury/multiple ? Side effects from treatments and /or medications) ? Anticipated healing time ? Treatment costs/concerns ? Functional Abilities Temporary /duration ? Employee Assistance Program (EAP) ? Medical Appointments ? Support Emotional

    ? Type/ length of treatment ? Family Support

    ? Waiting times/delays ? Other (please specify) ? Access/Scheduling to appointments


    Functional Abilities (identify current ability)

    ? Medical precautions ? Pre-existing functional limitations ? Tolerances? Risk level for re-injury

    ? Lifting limits ? Medical aids

    ? Work Habits/methods? Travel ability

    ? Recovery while working? Daily Living demands

    ? Other (please specify)


    Accommodation (identify impacts of injury/illness on home and work life)

    Demands of job Work Life balance Job/Work ? Physical Demands Analysis (PDA) ? Child/Elder Care ? Job suitability/task ? Essential Duties ? Daily living activities ? Workstation suitability ? Business considerations ? Other School ? Productivity / standards ? Productivity /standards ? Other work ? Work schedule ? Work Environment ? Work Schedule (flex) ? Work habits ? Other (please specify) ? Other (please specify) ? Training/ Development plan

     ? Other (please specify) In developing outcomes consider:

    ? Can health recovery occur at work?

    ? Does the employee’s functional ability enable them to meet the physical demands of the job?

    ? If not, what specific changes could be made to remove the barriers?

    ? Were any other barriers identified in your discussions?


SAMPLE: Return to Work Case Plan # 1

    (Page 1 of 3) Date: WSIB Claim #: This plan covers the time period from ____________to_____________ Employee: Phone #: Position: Manager: Phone #

    Health Recovery

    a) Anticipated recovery time:

    b) Treatment (scheduled or proposed):

    c) Appointment date(s):

    Functional Abilities

1) Identify source(s) of functional abilities and the date(s):

2) Has a Functional Abilities Form been completed?

     Yes, date: _________ If no, date expected __________

3) List the precautions, if any.

    Temporary Duration Permanent


     (Page 2 of 3)


Objectives (select one):

    1 Pre-injury job Work Comparable

    2 Pre-injury job accommodated Alternative Work

     Not Yes No Known

     1. Are the physical demands of the job within the employee’s functional


    3 2. Are the essential duties of the job within the employee’s functional


     3. Does the employee have the knowledge and skills required to do the

    job, where applicable?

     4. Does the job description accurately reflect the job being done?

    List the job tasks: (attach additional pages, if needed)

    Outline required modifications/accommodations to work duties: For example: technical aids, furniture,

    hours, productivity /quotas).

1 Work Comparablein nature and earnings to pre-injury with accommodation, if required 2 Alternative Work different job with accommodation, if required 3 "essential duties" = duties necessary to achieve the actual job outcome [The job outcome is the

    overall objective of the job in terms of production of the final product or provision of service]

    (Page 3 of 3)

    Develop Outcomes

    List the steps required to achieve the


Outline frequency of contact and by whom, if necessary, in addition to the specified

    follow-up dates:

    Work Schedule

    Follow-up cycle: (For example: weekly, bi-weekly etc.)

    Week with dates Days of Hours per day Duties


    Sample Monday, 3 hours General filing, replace telephone clerk

    Week 1: Feb 11th Thursday (9 am to 12 pm) for morning break 1. 2. 3. 4. 5.

Signatures or acknowledgement of receipt:

Employee: ____________________________ Date: __________________________

Manager: _____________________________ Date: __________________________

Sample Return to Work Plan - #2

    Name: Claim #: RTW Goal: Plan Start date: Pre-injury Job: Plan Completion Date:



Hours of work:

    Location of work:



Employee Signature: _______________________________________

    Employer Signature: ________________________________________

Print Name: _______________________________________________

    Print Name: _______________________________________________

Sample Return to Work Plan #3

Name: Claim #:

    Pre-injury job: Injury Date:

    Workplace location:

    Plan Start Date: Plan End Date:

    Return to Work Goal (agreed to by all parties):

    ? Pre-injury job

    ? Pre-injury Accommodated

    ? Work Comparable

    ? Alternative Work

Health Care Provider: Date of Contact:


Functional Abilities (what the employee can do):

    Action to be taken: Due date: Review

    date: Worker:


    Modification to the work duties required (attach details): Yes No

Training required (attach details): Yes No

Modifications to workplace required (attach details): Yes No

Week Days Hours Duties

    1 2 3 4 5 6 7 8 9 10

Supervisor Name: __________________________________________

    Supervisor Signature: _______________________________________

    Date: _____________________________________________________

If you have any problems with the duties or your progress please contact your

    manager or supervisor immediately, as well as your adjudicator.

Worker Name: ______________________________________________

    Worker signature: ____________________________________________

    Date: ______________________________________________________

Manager Name: ______________________________________________

    Manager Signature: ___________________________________________

    Date: _______________________________________________________

Sample Return to Work Progress Report #1





    (as written in the Return to Work Case Plan)

    (e.g.continue, revise or close the existing case plan)

Completed by:

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