Return to Work Plan Monitoring Form
Geography / All / Source: / WSCC
RETURN TO WORK PLAN MONITORING FORM
BENEFITS
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.
HOW TO USE THE TOOL
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.
OTHER RESOURCES:
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
RETURN TO WORK PLAN MONITORING FORM
Worker’s Name:Pre-injury Supervisor:
Modified Work Supervisor (if different):
Review Period Dates (from/to):
Hours Worked (attendance):
Week / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / SundayDuties Assigned: (list the work assigned during the review period)
Worker Comments / Employer Comments / Other Comments (Union, HR, WSCC) / Actions to address any concerns or comments / Date ReviewedComments or Concerns:
Is the modified work or RTW plan assisting in accomplishing the goals? Yes No
Comments:
Are there any other suggestions on how to improve the plan?
Next Steps: [such as revising the existing plan, continuing with plan, closing RTW plan]
Next Follow-up Date (if needed):
Signatures:
Employer: / Date:Worker: / Date:
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