Treating medical practitioner: Fit for suitable duties (restricted return to work) From: To: Phone: Job description: Suitable duties plan Task details Week Duties Restrictions Week 1 commencing: – Days: Hours: Week 2 commencing: – Days: Hours: Week 3 commencing: – Days: Hours: Week 4 commencing: – Days: Treatment occurring during this plan (e.g. physiotherapy): Training required: Yes No If given by: …… ‘Yes’, …… Plan to be reviewed on: Training given on: …… …… Signatures Treating medical practitioner Worker I have been consulted about the content of this plan and agree I approve this plan. to participate. Signature: ______________________Date: __________ Signature: ______________________Date: __________ Supervisor Rehabilitation and return to work coordinator I agree to ensure this plan is implemented in the work area. I agree to monitor this plan. Signature: ______________________Date: __________ Signature: ______________________Date: __________
Treating medical practitioner: Fit for suitable duties (restricted return to work) From: To: Phone: Job description: Suitable duties plan Task details Week Duties Restrictions Week 1 – commencing: Days: Hours: Week 2 – commencing: Days: Hours: Week 3 – commencing: Days: Hours: Week 4 – commencing: Days: Treatment occurring during this plan (e.g. physiotherapy): Training required: Yes No …… If ‘Yes’, given by: …… Plan to be reviewed on: …… Training given on: …… Signatures Treating medical practitioner Worker I approve this plan. I have been consulted about the content of this plan and agree to participate. Signature: ______________________Date: __________ Signature: ______________________Date: __________ Supervisor Rehabilitation and return to work coordinator I agree to ensure this plan is implemented in the work area. I agree to monitor this plan. Signature: ______________________Date: __________ Signature: ______________________Date: __________
Injury-information-pack_FINAL.docx