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Return to Work Program Generator

Prior to creating a program, you will need to complete the following items:

General Information

Organization name:

Organization address: Street: City: State: ZIP code:

Who will be in charge of the return to work program? Phone:

Who is responsible for writing job descriptions at your organization?

Insurance provider?

Policy Statement

Medical Provider Information Add

Medical provider name:

Medical provider specialty:

Medical provider address: Street: City: State: ZIP code:

Medical provider phone:

Remove Move

Transitional Work 650

Frequency AbbreviationNumber of Repetitions During ShiftPercentage of Time
Rare to Occasional (R/O)0-2033%
Frequent (F)20-10033-66%
Constant (C)>10066-100%
Default (--)N/AN/A
Task Lift/
Carry
(lbs.)
Stand/
Walk
Sit Drive Grip Bend Squat Climb
Remove Move

Add Task

Create Document
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