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Document Sample
Return to Work Release and Work Ability
Employee Name: __________________________________________
Return to Work
Return to work with no limitations on ________/________/__________
Return to work with limitations on _________/_________/__________ (note limitations below)
Employee’s Capabilities
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Not |
Occasio |
Freque |
Continuo |
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at |
nal |
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us |
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Lift/Carry |
all |
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No lifting |
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Push/Pull without resistance |
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> 40 lbs |
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Bend |
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Twist/turn |
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Kneel/squat |
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Sit |
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Stand/walk |
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Ladder/stair |
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climb |
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Hand, wrist, and shoulder activities |
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Avoid prolonged, repetitive, or forceful: |
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Gripping/grasping |
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Repetitive wrist |
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motion |
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Reaching |
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Above |
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shoulder |
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At shoulder |
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height |
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Below |
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shoulder |
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This treatment has been discussed with the employee.
Restrictions (circle) |
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Keyboarding / hrs |
0 |
1 - 2 |
3 – 4 |
5 – 6 |
7+ |
Writing / hrs |
0 |
1 - 2 |
3 – 4 |
5 – 6 |
7+ |
Change positions every:
As needed
Half hour
One hour
Two hours
Worksite stretches
Exercises
Other
Comments:
_________________________________________________ |
__________________________ |
Physician Signature |
Date |
Document Information
| Fact Name | Description |
|---|---|
| Definition | A Work Release form allows individuals to leave a correctional facility for employment purposes. |
| Eligibility | Typically, individuals must meet certain criteria, such as good behavior and a minimum sentence served. |
| Application Process | Individuals must submit a request to the facility’s administration to be considered for work release. |
| Supervision | Participants are usually supervised during their work hours and may be required to check in regularly. |
| State Variations | Each state has its own regulations governing work release, including eligibility and application procedures. |
| Governing Laws | In California, for example, Penal Code Section 4024.2 outlines the work release program. |
| Duration | The duration of work release can vary, often depending on the individual's sentence and behavior. |
| Benefits | Work release programs can help individuals reintegrate into society and provide financial support for families. |
| Consequences of Violation | Failure to comply with the terms of the work release can lead to revocation and additional penalties. |
| Support Services | Many programs offer support services, including job placement assistance and counseling. |
Work Release - Usage Guidelines
After you have gathered all necessary information, you are ready to fill out the Work Release form. Ensure you have your personal details and any required supporting documents at hand. Follow these steps carefully to complete the form accurately.
- Begin by entering your full name in the designated section at the top of the form.
- Provide your current address, including street, city, state, and zip code.
- Fill in your date of birth in the specified format.
- Next, indicate your contact number, ensuring it is a valid and reachable number.
- In the employment section, list your current employer’s name and address.
- Specify your job title and the nature of your work.
- Include the start date of your employment and, if applicable, your expected end date.
- Sign and date the form at the bottom to certify that all information provided is accurate.
Once you have completed the form, review it for any errors or missing information. After verifying its accuracy, submit it as instructed. Keep a copy for your records.
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Dos and Don'ts
When filling out the Work Release form, it is essential to approach the task with care. Here are some important dos and don'ts to keep in mind:
- Do read the entire form thoroughly before starting.
- Do ensure all personal information is accurate and up to date.
- Do double-check the dates and times you are requesting for work release.
- Do sign and date the form where required.
- Do submit the form to the appropriate authority in a timely manner.
- Don't leave any required fields blank.
- Don't provide false information or misrepresent your situation.
- Don't wait until the last minute to submit the form.
- Don't forget to keep a copy of the completed form for your records.
- Don't assume that verbal requests are sufficient; always use the form.
Common mistakes
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Failing to provide accurate personal information. This includes name, address, and contact details. Inaccuracies can lead to delays in processing.
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Not specifying the reason for the work release. A clear explanation is essential for approval.
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Omitting required signatures. All necessary signatures must be included to validate the form.
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Ignoring deadlines. Submitting the form late can result in denial of the request.
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Providing incomplete information regarding employment. This includes details about the employer and job responsibilities.
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Not including supporting documentation. Relevant documents that support the request should be attached.
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Failing to read instructions carefully. Misunderstanding the requirements can lead to mistakes.
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Using incorrect or outdated forms. Always ensure the most current version of the form is being used.
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Neglecting to follow up on the status of the request. Checking in can help address any issues promptly.