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.
DEVELOP INDIVIDUALIZED RETURN TO WORK PLANS
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
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 #
a) Anticipated recovery time:
b) Treatment (scheduled or proposed):
c) Appointment date(s):
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)
List the steps required to achieve the
Outline frequency of contact and by whom, if necessary, in addition to the specified
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:
DATE DUTIES FOLLOW-UP
Employee Signature: _______________________________________
Employer Signature: ________________________________________
Print Name: _______________________________________________
Print Name: _______________________________________________
Sample Return to Work Plan #3
Name: Claim #:
Pre-injury job: Injury Date:
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
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: _______________________________________
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: ____________________________________________
Manager Name: ______________________________________________
Manager Signature: ___________________________________________
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)