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Run: Return-to-Work and Job Demand Documentation

Document essential job demands, current functional capacity, and work restrictions in one return-to-work form. Use it to align HR, managers, and clinicians o...

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Submission Details

Employee name (required)

Employee ID

Optional if your organization uses an internal identifier for routing.

Department (required)

Current job title (required)

Who is completing this form? (required)

Submission date (required)

Job Demand Analysis

Essential physical demands (required)

Essential cognitive or attention demands

Essential schedule demands

Additional job demand notes

Describe any other essential duties or environmental demands that affect return-to-work planning.

Current Functional Capacity

Current work status (required)

Recommended return date

Maximum lifting capacity (lbs)

Enter the maximum safe lifting capacity in pounds.

Standing tolerance (minutes)

Sitting tolerance (minutes)

Functional capacity summary (required)

Summarize current abilities, limitations, and any relevant therapy or clinical guidance.

Work Restrictions and Accommodations

Are work restrictions recommended? (required)

Restriction types

Restriction details

Describe the restriction, duration, and any measurable limits.

Requested accommodations or job modifications

Expected restriction end date

Review, Consent, and Follow-Up

Consent to use this information for return-to-work planning (required)

I understand this form may contain PII and functional health-related information and consent to its use for return-to-work coordination, accommodation review, and related audit trail purposes.

Yes No N/A

Preferred follow-up contact method

Follow-up notes

Add any scheduling notes, review dates, or coordination details.

Submitter signature

Optional signature if your workflow requires attestation.

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Email (required)

Your name (optional)

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