Return-To-Work Index

Memorandum / Letter / Form Index

Return-To-Work Index

Ø Sent by Company Representative

Initial Notification to Superintendent of Return-to-Work Program

· Sent to all Superintendents to notify of program implementation (print on COMPANY letterhead).

Initial Notification to Employee of Return-to-Work Program

· Sent to all other employees to notify of program implementation. (print on COMPANY letterhead).

Ø Completed and sent by Company Representative

First Physician’s Contact Letter (Print on COMPANY letterhead)

· To be sent to the attending physician by the company representative upon first knowledge of provider. (Attach a Return-to-Work Authorization form.)

· Print Return-to-Work Authorization form.

Second Physician Contact Letter (Print on COMPANY letterhead)

· Follow-up letter one week after first letter sent. (Attach Temporary Alternate Work Assignment descriptions and a Return-to-Work Authorization Form.)

· Print Return-to-Work Authorization form.

Employee Letter of Concern

· To be sent whenever a State First Injury Report Form is received.

Employee RTW Responsibilities Form

· If a Return to Work Authorization release for temporary alternate work is received from the attending physician or the Claims Administrator, this form must be read by the employee and signed prior to entering the Return-To-Work Program.

MCCF

RTWINDX

MEMORANDUM

To: Superintendent

From:

Re: Company Name Return-to-Work Implementation

uReturn-to-Work Programu

Company Name‘s Return-to-Work Program is designed to aid in returning an injured/ill employee to the work force as soon as possible after an injury or illness.

It is our intent to place an injured/ill employee in a productive, Temporary Alternate Work Assignment that meets with the physical restrictions set forth by the employee’s physician. Early return to work is an effective way to reduce workers’ compensation disability costs.

Whenever possible, we try to place returning injured/ill employees in their regular department. If we are unable to accommodate the physical restrictions, employees can be placed in another department, if work is available. Company Name asks that you utilize Temporary Alternate Work Assignment employees in productive and meaningful work. The Return-to-Work Program is an important part of the recovery process and Superintendent cooperation is essential to the success of the program.

Company Name will assist you with any questions you might have regarding the Return-To-Work Program and will also be available to assist with any problems that may arise in the process of returning an injured employee to the work force.

Thank you.

MCCF

MEMO

MCCF

MEMO

MEMORANDUM

To: Employee

Date:

From:

Re: Company Name Return-to-Work Implementation

uReturn-to-Work Programu

Company Name S’ Return-to-Work Program is designed to aid in returning an injured/ill employee to the work force as soon as possible after an injury or illness. During the process of recovery an employee can work a Temporary Alternate Work Assignment. All assignments will meet with the physical restrictions set forth by the employee's physician.

Whenever possible, Company Name will place returning employees in their regular job modified. If the Superintendent is unable to accommodate the physical restrictions in his/her regular job, the employee will be placed in another area, if work is available. Injured/ill employees will be utilized in productive and meaningful work as determined by the company representative and/or Superintendent. Company Name realizes that returning to work as soon as possible is an important part of the recovery process.

Company Name can assist you with any questions you might have regarding the Return-to-Work Program and will also be available to assist with any problems that may arise in the process of returning to the work force.

Thank you.

MCCF

MEMO2

MCCF

MEMO2

Return-to-Work Authorization

Re: Patient :

Claim No. :

D/Injury :

Dear Physician:

Placement of injured employees into Temporary Alternate Work Assignments is one of the services offered by Company Name. We have a very flexible Return-to-Work Program and can usually offer Temporary Alternate Work Assignments to fit each employee's special needs.

We currently have a Temporary Alternate Work Assignment opening for the above patient. We feel it would be beneficial for this patient to be actively employed again and are anxious for his/her return to work.

When you determine the above patient is physically capable of returning to a Temporary Alternate Work Assignment, please complete the Return-to-Work Authorization and return to my attention. If you have reservations about any aspect of our program, please feel free to call.

Your cooperation in this matter is greatly appreciated.

Sincerely,

1STLTRPHY

Return-To-Work Authorization

Patient/Employee: / Date of Injury:
Please Select One of the Following:
q Worker Released to Regular Job Duties (NO RESTRICTIONS). / Date Released:
q Worker Released for TEMPORARY ALTERNATE ASSIGNMENT. / Date Released:
Total Number of Hours Employee May Work:______

Temporary Restrictions

Note: On terms of an eight hour work day: Limited (0-1 hour), Occasionally equals 1% to 25% (1-2 hours), Frequently equals 26% to 50% (3-4 hours), Repeatedly equals 51% to 75% (5-6 hours), and Continuously equals 76% to 100% (7+ hours). Not Restricted (NR). Circle/Check Appropriate Choice.

No. of Hours
Sit / 0 1 / 2 3 / 4 5 / 6 7 / 8 NR
Stand / 0 1 / 2 3 / 4 5 / 6 7 / 8 NR
Walk / 0 1 / 2 3 / 4 5 / 6 7 / 8 NR
Employee can alternately sit/stand every hours.
Limited / Occasionally / Frequently / Repetitively / Continuously
Hand/Wrist Work / q / q / q / q / q
Grasping / q / q / q / q / q
Pushing/Pulling / q / q / q / q / q
Fine Manipulation / q / q / q / q / q
Reaching / q / q / q / q / q
Bend / q / q / q / q / q
Kneel / q / q / q / q / q
Squat / q / q / q / q / q
Climb / q / q / q / q / q
Lifting 01-10 lbs. / q / q / q / q / q
Lifting 11-20 lbs. / q / q / q / q / q
Lifting 21-50 lbs. / q / q / q / q / q
Lifting 51-70 lbs. / q / q / q / q / q
q Time Loss Authorized - Because of objective findings, worker should remain off work.
· Projected date employee can perform temporary alternate work: / Date:
· Projected date employee can return to full duties: / Date:

Physician Comments

Is the patient involved in treatment and/or medication that might affect their ability to work safely in any capacity?
q No q Yes - Please explain:
Will the employee be required to use any devices or braces? q No q Yes - Please explain:______
Additional Comments:
Date:
Physician’s Signature

Company Name / MCCF James of Oregon, Inc.

RTWPRO - 8/19/11

Re: Patient :

Claim No. :

D/Injury :

Dear Physician:

On we sent a letter to you regarding Company Name‘s Return-to-Work Program. We just want to remind you that we can provide a Temporary Alternate Work Assignment for your patient.

Please review the enclosed Temporary Alternate Work Assignment descriptions. These assignments can be modified to meet any restrictions set forth by you. If you feel that eight hours is excessive for the employee, we can provide shortened hours within the temporary assignment.

We are willing to work within any work restrictions you deem appropriate. From past experience we have found that the longer employees stay away from work, the harder it becomes for them to return to the workforce. We also know that it is vitally important employees feel like a productive team member. This is why we do everything possible to return employees to the work site, unless an employee is bedridden.

We hope that you will work with us to return your patient to the workplace as soon as you feel he/she is capable. Please feel free to call if you have any questions, or would like to discuss these Temporary Alternate Work Assignments further.

Sincerely,

Enclosure

MCCF

REMIND -

Return-To-Work Authorization

Patient/Employee: / Date of Injury:
Please Select One of the Following:
q Worker Released to Regular Job Duties (NO RESTRICTIONS). / Date Released:
q Worker Released for TEMPORARY ALTERNATE ASSIGNMENT. / Date Released:
Total Number of Hours Employee May Work:______

Temporary Restrictions

Physician Comments

Company Name / MCCF James of Oregon, Inc.

RTWPRO - 8/19/11

Memorandum

To:

Date:

From:

uReturn-to-Work Programu

We are sorry to hear that you have suffered an injury/illness. Company Name has a program for returning injured/ill employees to a Temporary Alternate Work Assignment. The Return-to-Work Program enables you to remain in the work force while you are recovering from your injury/illness. While you are in the Return-to-Work Program you will earn your regular wage for hours worked.

We will be sending a letter to your physician describing Company Name’s Return-to-Work Program. The Temporary Alternate Work Assignments have been designed to ensure that restrictions set forth by your physician can be met. However, you are not guaranteed placement, it is dependent upon the physical restrictions set forth by your physician, the availability of a Temporary Alternate Work Assignment that meets your restrictions, or a projected release for return to regular work.

If your physician releases you for a Temporary Alternate Work Assignment, you must contact your superintendent and/or the office staff within one working day of your release. If you fail to do so, corrective action may be taken.

Additionally, Company Name will make reasonable accommodations for qualified individuals with disabilities under federal and state law, unless it would be an undue hardship.

If you have questions on compensation benefits or the Return-to-Work Program, please contact the superintendent or the office staff.

By the time you receive this letter, you may have already returned to work or you may not have experienced any time loss. We hope this information has been helpful in explaining the Return-to-Work Program.

Best wishes for a speedy recovery.

MCCF

LTRCON

MCCF

LTRCON

Employee RTW Responsibilities Form

While In The Return-To-Work Program

The Company Name Return-to-Work Program has been designed to provide temporary alternate work to injured employees by allowing them to continue receiving full pay and benefits while recovering. You will work in an assignment that meets your physical limitations. We value your work and the contributions you can give to Company Name. The assigned superintendent for the Temporary Alternate Work Assignment will explain the assignment, go over the expectations, train you, answer questions, and assist you with any help that you might need.

Follow these guidelines:

Alternate work is temporary and all Temporary Alternate Work Assignments are evaluated on a case-by-case basis. No Temporary Alternate Work Assignment will become permanent. If at any time during the course of your recovery it appears that you will be unable to return to your regular job, appropriate intervention will be initiated with your physician’s consent.

Show up for work on time, follow the instructions given to you by your superintendent, and ask questions whenever necessary.

All work provided will be consistent with, and will not exceed, the physical limitations set by your treating physician. IT IS YOUR RESPONSIBILITY TO MAKE SURE YOU DO NOT WORK BEYOND YOUR PHYSICAL LIMITATIONS. If any activities produce and/or aggravate symptoms, you should stop the work assignment and report to the superintendent.

You will be paid your regular wage while in a Temporary Alternate Work Assignment. You will be required to follow the same time keeping requirements as in your regular job.

If you are unable to report to your Temporary Alternate Work Assignment, for any reason, you are to call your superintendent and/or the office staff and advise of your absence.

As a Return-to-Work Program participant, you are encouraged to schedule physical therapy and physician appointments at times when you are not expected to be at work. If you must leave your assignment, all appointments requiring time away from work must be approved/recorded by your superintendent and verified by your physician.

It is YOUR RESPONSIBILITY to perform your Temporary Alternate Work Assignment in a responsible and professional manner, as you would your own regular job. Failure to do so, for example, non-performance of assigned duties, tardiness, not calling in when absent, etc., will result in the same corrective action as would have occurred if you had been working in your regular job. Your Superintendent will handle any problems requiring corrective action.

If due to a worsening of your condition your attending physician takes you off work again, please contact your superintendent and the main office immediately. Remember, for any medical absences from work related to your injury, authorization from your attending physician is needed for you to receive time loss benefits.

If you have been released for a Temporary Alternate Work Assignment, and an assignment is available that meets the restrictions set forth by your attending physician, and you refuse the assignment, your time loss benefits will be terminated.

Your superintendent, the office staff, and the MCCF Claims Administrator will monitor your progress until your physician has released you to your regular job.

I understand my responsibilities as an employee in the Company Name Return-to-Work Program.