Return to Work Plan

Employer Details

• Business Name: [Insert Business Name]
• ABN: [Insert ABN]
• Contact Person: [Insert Name]
• Phone Number: [Insert Phone Number]
• Date of Plan: [DD/MM/YYYY]

Worker Details

• Worker Name: [Insert Full Name]
• Job Title: [Insert Job Title]
• Date of Injury/Illness: [DD/MM/YYYY]
• Date of Injury/Illness: [DD/MM/YYYY]
• Date of Commencement of this Plan: [DD/MM/YYYY]
• Expected Date of Full Return to Work: [DD/MM/YYYY]

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1. Medical Information

Treating Doctor: [Insert Doctor Name]

• Medical Practice: [Insert Practice Name]
• Date of Certificate of Capacity: [DD/MM/YYYY]

Current Capacity:

• Fit for pre-injury duties? [Yes/No]
• Fit for suitable duties? [Yes/No]
• Work Hours Capacity: [e.g. 4 hours per day, 3 days per week]

Restrictions / Limitations:

• [Insert restrictions, e.g. No lifting over 10kg, No working above shoulder height, No driving heavy vehicles]

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2. Proposed Suitable Duties

Position Title for Suitable Duties: [Insert Title, e.g. Administration Assistant, Light Labourer]

Hours of Work:

• Start Time: [e.g. 8:00 AM]
• Finish Time: [e.g. 12:00 PM]
• Days: [e.g. Monday, Wednesday, Friday]
• Total Hours per Week: [Insert Number]

Duties and Tasks:

Task Description	Estimated Time	Frequency	Supervision Required
[e.g. Answering phones]	[e.g. 1 hour]	[e.g. Daily]	[e.g. Yes - Initial training]
[e.g. Organising inventory]	[e.g. 2 hours]	[e.g. Weekly]	[e.g. No]
[e.g. Filing paperwork]	[e.g. 1 hour]	[e.g. Daily]	[e.g. No]

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3. Workplace Modifications and Support

Modifications Required:

• [List any changes, e.g. Ergonomic chair provided, Step stool for reaching low shelves]

Equipment Provided:

• [List equipment, e.g. Headset, Lifting trolley]

Training Required:

• [List any training, e.g. Manual handling refresher course]

Support Person:

• Name: [Insert Supervisor/Mentor Name]
• Role: [Insert Role]

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4. Monitoring and Review

Review Dates:

• First Review: [DD/MM/YYYY]
• Second Review: [DD/MM/YYYY]

Key Performance Indicators for Recovery:

• [e.g. Increase hours by 2 hours per week after 4 weeks]
• [e.g. Gradual introduction of lifting tasks up to 10kg]

Plan Graduation:

• This plan will be reviewed for an upgrade to [Next Level of Duties] on [Date].

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5. Agreement and Signatures

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

Employer Representative: Signature: _________________________ Name: _________________________ Date: _________________________

Worker: Signature: _________________________ Name: _________________________ Date: _________________________

Treating Health Practitioner (if required by insurer): Signature: _________________________ Name: _________________________ Date: _________________________