The Work Release form is a crucial document that allows individuals to participate in employment while fulfilling certain legal obligations. This form not only facilitates a smoother transition back into the workforce but also supports rehabilitation efforts. Ready to take the next step? Fill out the form by clicking the button below.
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The Work Release form is often accompanied by various other documents that facilitate the process of employment while on a work release program. Below is a list of common forms and documents that may be used alongside the Work Release form, each serving a specific purpose.
These documents play a crucial role in ensuring that the work release process is transparent and well-organized. Each form contributes to the overall management and success of the individual's transition back into the workforce.
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
Not
Occasio
Freque
Continuo
at
nal
nt
us
Lift/Carry
all
0-33%
34-66%
67-100%
0-9 lbs
10-19 lbs
20-29 lbs
30-39 lbs
40-49 lbs
No lifting
Push/Pull without resistance
0-19 lbs
20-40 lbs
> 40 lbs
Bend
Twist/turn
Kneel/squat
Sit
Stand/walk
Ladder/stair
climb
Hand, wrist, and shoulder activities
Avoid prolonged, repetitive, or forceful:
Gripping/grasping
Repetitive wrist
motion
Reaching
Above
shoulder
At shoulder
height
Below
This treatment has been discussed with the employee.
Restrictions (circle)
Keyboarding / hrs
0
1 - 2
3 – 4
5 – 6
7+
Writing / hrs
Change positions every:
As needed
Half hour
One hour
Two hours
Worksite stretches
Exercises
Other
Comments:
_________________________________________________
__________________________
Physician Signature
Date