Medical Restrictions Form HCP-1

Medical Restrictions Form HCP-1
Health Care Practitioner Information:
This company recognizes that the provision of alternate or modified work is important in the
prevention of disability and has established a Return-to-Work Program for employees who are
unable to perform any or all of their normal duties as a consequence of an injury/illness.
The purpose of this form is to verify injury/illness and to provide restrictions in order to enable the
worker to return to alternate or modified work as soon as possible.
We require this information in order to identify suitable work that is both productive and safe.
Any work assignments will honour the outlined restrictions.
If we are unable to offer work that is appropriate to the outlined restrictions the worker will be off
work.
Please provide the worker’s current capabilities and/or restrictions, and the expected duration of any
restrictions (i.e. no lifting until musculoskeletal assessment).
It is expected that all restrictions will be based upon objective medical evidence.
Worker Instructions:
•
Report injuries and absences for medical reasons to your supervisor immediately
•
Obtain medical treatment
•
Have your health care practitioner complete the medical restrictions form (on back) during your
initial visit to provide you with your restrictions
If medical restrictions do not affect your ability to do your job:
•
Return to work for your next scheduled shift
•
If medical restrictions affect your ability to do your job:
•
Call your supervisor as soon as possible to let him/her know that your injury has affected your
ability to do your job
•
At your RTW planning meeting you will be provided (if possible) with suitable work within your
restrictions as outlined on the medical restrictions form. The alternate or modified work will:
•
-
honour your current medical restrictions
-
be modified if and/or when your medical restrictions change
-
allow time for further diagnostic and/or treatment appointments
Have your health care practitioner complete another medical restrictions form during any followup appointments if your medical restrictions change
Company Name and Address:
Medical Restrictions Form
The purpose of this form is to verify injury/illness and to provide restrictions to the employer in order to
enable the worker to return to alternate or modified work as soon as possible.
The employer requires this information in order to identify suitable work that is both productive and safe.
Any work assignments will honour the outlined restrictions.
If the employer is unable to offer work that is appropriate to the outlined restrictions the worker will be off
work.
Please complete and give to worker for delivery to the employer.
Worker’s Name:
Due to injury/illness the following restrictions currently apply:
Expected duration of restrictions:
<7days
8-14 days
15-21 days
Practitioner Name and Signature
>21 days
Date
Form HCP-1
Health Care Practitioner not required to send copy to WCB
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