Sample Checklist for Managing Return to Work Initial Management Injury reported? Date: __________ Worker Name: Supervisor Name: Date of Injury/Illness: Provided first aid or medical attention, and transportation to a health care facility? Fully complete and submit an Employer’s Report of Injury form to the WSCC? Date: _________ Organization incident investigation completed? Y N Functional Abilities form returned? Y N Expected return to work date: __________________ Maintain communication with worker and document in Communications Log. Return to Work Plan Meet with worker to discuss RTW. Date: ___________ Physical demands of pre-injury job or transitional job duties match the worker’s functional abilities? Y N Document, sign, and provide RTW plan: Date:______________ Submit RTW plan to the WSCC. Date:___________ Monitor and Evaluate Regular meetings with worker to evaluate RTW plan Date:_____________ Date:____________ Date: ______________ Contacted WSCC Case Manager to keep them informed of RTW Date: ____________ Date: _____________ Date: ______________ Provide worked to WSCC Case Manager Complete monitoring form. Date:____________ Resolve any issues that arise. Completion Employee returns to regular job duties and hours. Date: __________ Employee offered long term or permanent accommodation: Date: __________ Employee and supervisor evaluate the RTW plan and program and suggest improvements for future RTW situations. NOTES:
Sample Checklist for Managing Return to Work Worker Name: Supervisor Name: Date of Injury/Illness: Initial Management Injury reported? Date: __________ Provided first aid or medical attention, and transportation to a health care facility? Fully complete and submit an Employer’s Report of Injury form to the WSCC? Date: _________ Organization incident investigation completed? Y N Functional Abilities form returned? Y N Expected return to work date: __________________ Maintain communication with worker and document in Communications Log. Return to Work Plan Meet with worker to discuss RTW. Date: ___________ Physical demands of pre-injury job or transitional job duties match the worker’s functional abilities? Y N Document, sign, and provide RTW plan: Date:______________ Submit RTW plan to the WSCC. Date:___________ Monitor and Evaluate Regular meetings with worker to evaluate RTW plan Date:_____________ Date:____________ Date: ______________ Contacted WSCC Case Manager to keep them informed of RTW Date: ____________ Date: _____________ Date: ______________ Provide worked to WSCC Case Manager Complete monitoring form. Date:____________ Resolve any issues that arise. Completion Employee returns to regular job duties and hours. Date: __________ Employee offered long term or permanent accommodation: Date: __________ Employee and supervisor evaluate the RTW plan and program and suggest improvements for future RTW situations. NOTES:
10%20Sample%20Checklist%20for%20Managing%20Return%20to%20Work.docx