Return to Work Plan Example
Example document for Return to Work Plan. Use this as a reference when creating your own.
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Document: Return to Work Plan
Example Document
Last updated 7/27/2026
Return to Work Plan
Employer Details
- Business Name: Smith & Sons Plumbing
- ABN: 12 345 678 901
- Contact Person: John Smith
- Phone Number: 0412 345 678
- Date of Plan: 15/10/2023
Worker Details
- Worker Name: Michael Jones
- Job Title: Plumber
- Date of Injury: 01/09/2023
- Date of Commencement of this Plan: 16/10/2023
- Expected Date of Full Return to Work: 01/12/2023
1. Medical Information
Treating Doctor: Dr. Sarah Lee
- Medical Practice: City Medical Centre
- Date of Certificate of Capacity: 14/10/2023
Current Capacity:
- Fit for pre-injury duties? No
- Fit for suitable duties? Yes
- Work Hours Capacity: 5 hours per day, 4 days per week
Restrictions / Limitations:
- No lifting heavier than 10kg.
- No repetitive twisting of the lower back.
- No working in deep trenches or confined spaces.
- Must take a 10-minute break every hour for stretching.
2. Proposed Suitable Duties
Position Title for Suitable Duties: Workshop and Inventory Coordinator
Hours of Work:
- Start Time: 7:00 AM
- Finish Time: 12:00 PM
- Days: Monday to Thursday
- Total Hours per Week: 20
Duties and Tasks:
| Task Description | Estimated Time | Frequency | Supervision Required |
|---|---|---|---|
| Organising and inventorying van stock | 2 hours | Daily | Yes - Initial oversight |
| Ordering parts via supplier portals | 1 hour | Daily | No |
| Assembling small pipe kits (sitting) | 1 hour | Daily | No |
| Answering client service calls | 1 hour | Daily | No |
3. Workplace Modifications and Support
Modifications Required:
- A sturdy chair with back support has been placed at the workbench.
- All heavy inventory items have been moved to waist-height shelves.
Equipment Provided:
- Dolly for moving boxes of fittings (eliminates lifting).
Training Required:
- Review of updated inventory software system.
Support Person:
- Name: David Brown (Workshop Manager)
- Role: Oversees duties and ensures restrictions are followed.
4. Monitoring and Review
Review Dates:
- First Review: 30/10/2023
- Second Review: 13/11/2023
Key Performance Indicators for Recovery:
- Michael reports no increase in pain levels after two weeks.
- Increase work hours to 6 hours per day starting 06/11/2023.
Plan Graduation:
- Michael will try a half-day site visit with supervision on 20/11/2023.
5. Agreement and Signatures
Employer Representative: Signature: [John Smith Signature] Name: John Smith Date: 15/10/2023
Worker: Signature: [Michael Jones Signature] Name: Michael Jones Date: 15/10/2023
Notes
This example shows a trade business owner helping a plumber with a back injury. The plan removes physical risks like heavy lifting and trench work. It replaces them with sedentary or light duties in the workshop. The plan includes specific hours and tasks. It also names a support person to monitor the situation. The review dates ensure the plan is updated as the worker recovers.
About this Example
Part of the Return to Work Plan document collection
Document Type
Return to Work Plan
A formal written agreement between an employer and worker outlining the steps for an employee to return to work safely after an injury or illness. It helps manage duties, hours, and support while meeting Australian legal obligations.