Return to Work Plan Monitoring Form

Tool Type / FORM / Last Reviewed / 3/22/15
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 / Sunday

Duties 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 Reviewed

Comments 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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