Phased Return-to-Work Plan Template

Employee Information

Employee Name Job Title Department Manager/Supervisor Date of Phased Return Start

Phased Return Plan Overview

Summary of Adjustments Goals during Phased Return

Weekly Schedule

Week	Dates	Planned Hours/Days	Tasks/Responsibilities	Comments/Adjustments

Support and Adjustments

Details of Support Provided Workplace Adjustments

Review and Monitoring

Review Date(s) Notes from Review(s)

Signatures

Employee Date Manager/Supervisor Date