Return-to-Work Health Assessment Form
Employee Name
Employee ID
Department
Position/Title
Date of Assessment
Date of Expected Return
Health Information
Reason for Absence
Medical Diagnosis (if applicable)
Are you currently experiencing any symptoms?
No
Yes
If yes, please describe:
Current Medications
Physician or Health Care Provider Name
Contact Details of Health Care Provider
Any Work Restrictions or Accommodations Needed?
No
Yes
If yes, please specify:
Employee Declaration
Employee Signature
Date
For Office Use Only
Reviewed by
Date
Comments