<p>TOOL TYPE FORM LAST REVIEWED 3/22/15 GEOGRAPHY ALL SOURCE: WSCC </p><p>RETURN TO WORK PLAN MONITORING FORM</p><p>BENEFITS</p><p>When an injured or ill worker is able to come back, you should develop an appropriate return to work (RTW) plan for them. And to ensure that the plan is effective and is working for both the worker and the workplace, you should monitor the plan’s progress.</p><p>HOW TO USE THE TOOL</p><p>Adapt this Return to Work Plan Monitoring Form your workplace and RTW program. Employers and workers should use this form to assist in tracking progress throughout the RTW plan.</p><p>OTHER RESOURCES:</p><p>WSCC The 7 Principles for Successful RTW Injured Workers: How to Comply with Rwturn-to-Work Requirements Return to Work Contact Log Model RTW Weekly Assessment Form RTW Plan Questionnaire </p><p>T HI S TOOL A ND H U N DR E D S M OR E AVA I L A B L E IN T H E OHS TO OL BOX AT www.ohsinsider.com. Templates and tools from OHS Insider are provided for members of our service. Members may use this document as is or as a starting point to customize their own documents. OHS Insider assumes no responsibility for the effectiveness or legality of any of its online templates or tools. Always consult your legal counsel and management before implementing any new policies or procedures. RETURN TO WORK PLAN MONITORING FORM</p><p>Worker’s Name:</p><p>Pre-injury Supervisor: Modified Work Supervisor (if different): Review Period Dates (from/to):</p><p>Hours Worked (attendance): Week Monday Tuesday Wednesday Thursday Friday Saturday Sunday</p><p>Duties Assigned: (list the work assigned during the review period)</p><p>Worker Employer Other Comments Actions to address any Date Comments Comments (Union, HR, WSCC) concerns or comments Reviewed</p><p>Comments or Concerns: Is the modified work or RTW plan assisting in accomplishing the goals? Yes No</p><p>Comments:</p><p>T HI S TOOL A ND H U N DR E D S M OR E AVA I L A B L E IN T H E OHS TO OL BOX AT www.ohsinsider.com. Templates and tools from OHS Insider are provided for members of our service. Members may use this document as is or as a starting point to customize their own documents. OHS Insider assumes no responsibility for the effectiveness or legality of any of its online templates or tools. Always consult your legal counsel and management before implementing any new policies or procedures. Are there any other suggestions on how to improve the plan?</p><p>Next Steps: [such as revising the existing plan, continuing with plan, closing RTW plan]</p><p>Next Follow-up Date (if needed): </p><p>Signatures:</p><p>Employer: Date:</p><p>Worker: Date: </p><p>T HI S TOOL A ND H U N DR E D S M OR E AVA I L A B L E IN T H E OHS TO OL BOX AT www.ohsinsider.com. Templates and tools from OHS Insider are provided for members of our service. Members may use this document as is or as a starting point to customize their own documents. OHS Insider assumes no responsibility for the effectiveness or legality of any of its online templates or tools. Always consult your legal counsel and management before implementing any new policies or procedures.</p>