RETURN TO WORK PLAN

Worker Details Name: [FULL NAME OF WORKER] Job Title: [JOB TITLE] Date of Injury: [DATE OF INJURY] Date of Return to Work: [START DATE OF PLAN] Claim Number: [INSURANCE CLAIM NUMBER IF KNOWN]

Plan Details Plan Review Date: [DATE TO REVIEW PROGRESS] Supervisor: [NAME OF PERSON SUPERVISING THE RETURN] Medical Practitioner: [NAME OF DOCTOR OR TREATING HEALTH PROFESSIONAL]

Medical Capacity This plan is based on the medical advice provided by [DOCTOR NAME] on [DATE OF CERTIFICATE]. The current medical capacity indicates the worker can perform:

[INSERT DETAILS OF MEDICAL CAPACITY E.G. LIGHT DUTIES, NO LIFTING OVER 5KG, STANDING FOR MAX 30 MINUTES]

Proposed Duties The following duties are proposed for the worker during this recovery period:

1. [DESCRIPTION OF DUTY 1]
2. [DESCRIPTION OF DUTY 2]
3. [DESCRIPTION OF DUTY 3]

Hours of Work Start Time: [START TIME] Finish Time: [FINISH TIME] Days: [DAYS OF WEEK E.G. MONDAY TO WEDNESDAY] Total Hours Per Week: [TOTAL HOURS]

Workplace Modifications List any changes made to the workplace or equipment to assist the worker:

1. [MODIFICATION 1]
2. [MODIFICATION 2]

Risks and Controls List specific risks related to the injury and how they are controlled:

• Risk: [RISK 1] Control: [CONTROL MEASURE]
• Risk: [RISK 2] Control: [CONTROL MEASURE]

Signatures By signing below, we agree to the details of this Return to Work Plan.

Worker Signature: __________________________ Date: //____

Employer/Supervisor Signature: __________________________ Date: //____

If applicable, Return to Work Coordinator Signature: __________________________ Date: //____