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RTW FORM.pdf
Handle: Document-84965
Owner: Williamson, DeeAnn (User-264, 06177:EVERETT)DS
Thursday, December 8, 2016 07:58:54 AM PST
Thursday, December 8, 2016 07:58:54 AM PST
Modified By:
Locked By:
  • Name of Employee: Employee ID #:
Released to return to work effective: Restrictions: YES NOIMPORTANT: Please complete the following items based on your clinical evaluation of the above captioned and other testing results.
  • B.
  • 6-10 lbs.
  • C.
  • 11-20 lbs.
  • F. 51-100 lbs.
3. Employee can carry: Never Occasionally Frequently ContinuouslyA. Up to 5 lbs. D. 21-25 lbs.E. 26-50 lbs. YES NOComments:
Allowed
Adobe Portable Document Format (.pdf) - application/pdf
RTW FORM.pdf
No
4
36321
No
Appears In: The Scoop
Preferred Version: RTW FORM.pdf