Sample return-to-work program

To create your own return-to-work program, copy and paste the information below into a word document, to which you may wish to add your own company logo and address. Then fill in your company name or the appropriate information. You may simply print out from this document pages to be filled in by hand.

 

Sample forms and letters

• Program handbook 
• Return-to-work checklist 
• Employee contact log 
• Sample letter to physician — return-to-work program 
• Attending physician’s report: Return-to-work recommendations
• Sample letter to employee — offer of transitional duty 
• Employee and supervisor work restriction acknowledgment 

 

Program handbook

Introduction

A return-to-work (RTW) program is intended to help employees get back to work as soon as they are able, following an injury or illness.

<<Our Company>> has implemented a RTW program that is intended to bring employees back to work as soon as they are physically able, to perform work that is meaningful, without aggravating their injury or illness.

RTW has many benefits for the employee. It helps reduce the financial burden of being out of work, it often helps in the healing process by keeping the employee physically and mentally active, and it keeps the employee connected to their friends and co-workers. Therefore, <<Our Company>> will do its best to arrange temporary alternate or modified work (aka “transitional duty”) assignments whenever possible, for employees who are ill or injured.

 

Elements of a return-to-work program

An effective RTW program requires the following:

• Immediate reporting of injuries and illnesses to The Hanover.
• Use of The Hanover’s workers’ compensation medical provider network, whose members have agreed to practice return-to-work principles. To find network members in our area, visit hanover.com/workers-compensation-provider-networks.
• A “jobs bank” of potential “transitional duty” tasks.
• A coordinated team approach among <<Our Company>>, the injured employee, the medical provider and The Hanover.
• Training of <<Our Company>> employees in the elements of the RTW program.

 

Return-to-work coordinator

The return-to-work coordinator (RTWC) is an employee of <<Our Company>> responsible for developing and maintaining a list of transitional duty jobs and their physical requirements. The RTWC will also maintain frequent communications with the injured or ill employee, the employee’s medical provider and The Hanover. In addition, the RTWC will train employees in their responsibilities under the RTW program.

<<Name>> is the RTWC and is responsible for all aspects of <<Our Company’s>> RTW program. The RTWC will:

• Maintain the RTW program, and related records and forms, up-to-date.
• Make sure the first report of injury forms are completed and sent to the appropriate parties.
• Locate and use members of The Hanover’s workers’ compensation medical provider network (or recommend their use if state law does not allow requiring their use).
• Give the medical provider information on the physical requirements of the employee’s job, and potential alternate or modified transitional duty assignments.
• Maintain contact with the injured employee on a regular basis.
• Work with the physician to develop a transitional duty work plan.
• Communicate frequently with the medical provider and The Hanover.
• Train employees on <<Our Company’s>> RTW program.

 

Employee responsibilities

Supervisors employed at <<Our Company>> are responsible for assuring that:

• Anyone who is injured receives prompt medical attention.
• They contact the injured employee on a regular basis.
• The RTWC is made aware of all injuries and illnesses.
• The RTWC has assistance needed to develop a list of transitional duty jobs that employees with medical work restrictions can perform.
• There is a positive work atmosphere and environment where the returning employee feels welcome.
• Anyone returning to work does their job (or an alternate job) within limitations established by the physician.

All employees play a critical role in the success of the RTW program. They have the best understanding of the requirements of their jobs.

All employees of <<Our Company>> will:

• Report all injuries and illnesses immediately.
• Follow all <<Our Company>> protocols for safety and health.
• Assist the RTWC in completing necessary forms.
• Stay in touch with the RTWC on a regular basis if they become injured.
• Follow the physician’s directives, never working beyond medical restrictions.
• Take part in the RTW training that is provided by the RTWC.

 

Physical requirements and transitional duty

The RTWC will develop an analysis of the physical requirements of each job function, to be given to the injured employee’s treating physician if and when an injury occurs. The RTWC will also develop a “jobs bank” of transitional duty assignments for employees who are recovering from an injury or illness.

 

When an injury or illness occurs

<<Our Company>> will assure that prompt medical attention is provided to anyone who is injured. If feasible in the event of serious injuries, the employee’s supervisor should accompany them to their initial medical treatment.

Each case will be managed carefully, with the goal of bringing the employee back to work as soon as they are physically able, without aggravating the injury or illness. Members of The Hanover’s workers’ compensation medical provider network will be used (or their use recommended if state law does not allow requiring their use).

The physician is responsible for establishing work restrictions, if any. <<Our Company>> will provide transitional work assignments that are within the restrictions established by the physician. Removal from work will be avoided whenever possible.

The RTWC will take a proactive approach to providing the physician with the following information once an injury occurs:

• The injured employee’s job title and job responsibilities.
• A list of alternate or modified transitional duty jobs that could be performed.
• Attending physician’s report: Return-to-work recommendations form or state equivalent. (The employee should be asked, if possible, to bring this form with them when they receive medical treatment.)

The medical provider or treating physician may tour <<Our Company>> to become familiar with the physical requirements of the jobs being performed, and to be better able to recommend transitional duty assignments for injured or ill employees.

Once medical treatment has been provided, the RTWC should obtain the following from the treating physician:

• Jobs or work assignments that the employee is capable of performing.
• Tasks that the employee is restricted from performing.
• Length of time restrictions are recommended to be in place.
• A treatment schedule that includes dates for any follow up treatment(s) and/or physical therapy/rehabilitation.
• Written acknowledgment that the physician has explained restrictions to the employee, and provided the employee with a copy.
• Estimated date the employee should be able to return to normal duties.

It cannot be overemphasized that the injured employee must be monitored, to assure they work within the restrictions recommended by the treating physician. Employees may feel well enough to return to their regular responsibilities, but can risk further injury or could prolong the length of transitional duty by doing so. If the employee wishes to exceed physical restrictions, a release must be obtained from the physician.

 

Prompt notification to The Hanover

The RTWC will make sure that the employer’s first report of injury form is completely filled out, and that contact is made with The Hanover claims department, ideally the same day, but no more than 48 hours after the injury or illness. The RTWC should immediately contact the The Hanover claims department if the injury or illness is severe.

To report a workplace injury call The Hanover’s 24/7 toll free number at 800-628-0250, fax the report to 800-762-7788, or file a report online at: https://www.hanover.com/businesses/products/workers-compensation

Employees who suffer a serious injury or illness may be assigned to a Hanover nurse case manager. The nurse may contact the injured employee by phone or in person. The goal of the nurse case manager is to work with the employee, the physician, medical specialists and others, in order to speed the employee’s return to restricted, modified or full duty.

After the injured or ill employee receives medical treatment and has been evaluated by the physician for potential transitional duty assignment, the RTWC will assist in returning the employee to work as soon as they are physically able by doing the following:

• Make contact with the injured employee, preferably by phone, within one day of the injury if possible. In the event of a serious injury requiring hospitalization, the employee should be visited in the hospital as soon as possible.
• Inform the employee that they will receive a phone call and/or visit at least once per week, from the RTWC or the employee’s supervisor, until they return to work. Inform them that the purpose of this call is to see how their treatment is progressing and to see if they need any assistance from their supervisor or the RTWC.
• Send or bring a gift and/or get well card to the employee, signed by co-workers.
• Contact the employee’s treating physician and/or case nurse at least every two weeks, to confirm that the employee is receiving prescribed treatment, and to inform the physician or nurse of any developments regarding transitional duty assignments.
• Contact The Hanover claim department every two-four weeks to exchange information about the claim.

As soon as the employee has been authorized to return to work, a written offer of an alternate job, or their regular job with restrictions, should be made. The offer should be sent by certified return receipt mail or with tracking and signature required, to document that the employee has received it. The letter should describe the specific aspects of the restricted assignment. A copy of the job offer should be sent to The Hanover.

Before the employee resumes work the RTWC should review the employee’s work restrictions with the employee and the employee’s supervisor.

On each doctor visit made by the employee during the period of work restriction, the employee should ask the physician to fill out the attending physician’s report: return to work recommendations or state equivalent form.

The employee’s work activities should be monitored to assure work restrictions are not exceeded.

 

RTW training

The RTWC will provide RTW program training to new employees during the first 30 days of employment. Refresher training will be provided as necessary, and whenever changes are made to the RTW program. At a minimum training should communicate:

• Benefits of RTW for the employee: It helps reduce the financial burden of being out of work, it often helps in the healing process by keeping the employee physically and mentally active, and it keeps the employee connected to their friends and co-workers.
• Expectation that employees will return to work from injury or illness as soon as they are able to do so.
• Expectation that employees will use members of The Hanover’s workers’ compensation medical provider network (or their use should be recommended if state law does not allow requiring their use).
• <<Our Company>> will provide alternate or modified transitional work assignments to accommodate the work restrictions established by the employee’s treating physician.
• Employees will report injuries immediately.

Additional training should be provided for supervisors on their responsibilities in the RTW program.

 

RTW records

The RTWC is responsible for maintaining records associated with the RTW program, including the following:

• Documentation of RTW training, including employee names and dates training was conducted.
• A “jobs bank” of potential transitional duty tasks.
• Completed first reports of injuryThe Hanover’s workers’ compensation medical provider network.
• Physician’s reports of work restrictions.

Transitional duty assignments

Potential alternate work assignments, and ways to modify existing jobs to accommodate restrictions, should be determined before an injury or illness occurs. The RTWC should meet with other employees at <<Our Company>> to identify assignments that could be performed by employees with work restrictions. Each job should be analyzed and an inventory of transitional duty tasks determined. Often there are important jobs or projects that are currently not being done, but could be performed by an employee with restrictions. Other times, an employee can perform part or even most of their regular job, but needs assistance with certain tasks from another employee or by modifications to their workstation.

Examples:

“Sit-in-place” tasks — sitting with occasional walking and light lifting

• Working at computer
• Opening mail
• Ordering supplies
• Processing invoices and payments
• Answering telephone
• Updating manuals and best practices

“On-your-feet” tasks — walking and standing, moderate lifting, up to physician restrictions

• Filing
• Taking inventory
• Vacuuming or sweeping
• Light assembly or manufacturing tasks

“One-arm” tasks — can be performed with one hand or arm

• Phone with headset
• Sorting mail
• Light assembly or manufacturing tasks
• Employee’s regular job duties with the assistance of a workstation modification

“Job sharing”— specific tasks that exceed restrictions are shared with other employees

• Employee is paired with another employee, with tasks that exceed restrictions performed (or assisted) by the non-injured employee, and if possible, tasks that are within restrictions traded to the injured employee.
• Same as above, but job sharing is rotated among one than one employee, for instance a different employee each day of the week.
• Entire jobs are rotated among employees, thereby reducing the amount of time the injured employee spends doing more strenuous tasks (assuming this time period is within the employee’s restrictions).

Job modification — regular job of the injured employee is modified to meet restrictions.

• Employee’s workstation is modified, such as by providing material handling aids, adjustment of height and/or reach distances, assembly fixtures, power tools, ergonomically designed tools, modification to a sitting workstation, etc. It is often found that these workstation modifications can reduce injuries and improve productivity for all employees.
• Employee’s work hours are reduced, for instance working half days or taking additional breaks, and if necessary sharing their job with a part time or temporary employee.

 

Return-to-work checklist

Instructions: If the injured employee returns to work and there is no lost time, use lines 1-11. If there is lost time and the employee is not able to return to work right away, also complete lines 12-17.

Employee Name:______________________________________ Date of Injury:________________________________

 

1. Employee received prompt medical attention
2. Used member of The Hanover’s workers’ compensation medical Provider network (or recommended their use if state law does not allow requiring their use)
3. Injury reported to The Hanover within 24 hours (Phone: 800-628-0250, Fax: 800- 762-7788, or online at https://www.hanover.com/businesses/products/workers-compensation)
4. If employee was transported to hospital, The Hanover was called immediately
5. Blank form: “Attending physician’s report: Return-to-work recommendations” sent to physician
6. List of transitional duty jobs sent to physician
7. Employee contacted employer immediately after examination to discuss outcome of exam, any restrictions or transitional work required
8. Restrictions obtained from physician within 48 hours of examination
9. The Hanover claim representative notified of any restrictions, and date employee is able to return to work
10. Supervisor advised of any work restrictions and availability
11. Employee monitored to assure work restrictions are not exceeded

 

If employee is not returning to work right away:

12. Employee sent gift and/or get well card
13. Employee regularly contacted in person or by phone by RTWC
14. Employee regularly contacted in person or by phone by employee’s supervisor
15. The Hanover claims representative or nurse case manager contacted whenever an update is received from physician on medical status
16. Transitional duty offer letter sent upon receipt of physician clearance
17. Employee returns to work and restrictions, if any, are explained.       “work restriction acknowledgment” form is signed by employee and supervisor.

 

Employee contact log

Instructions: The employee should receive a phone call and/or visit at least once per week, from the RTWC or the employee’s supervisor, until they return to work. The purpose of this call is to see how their treatment is progressing and to see if they need any assistance from their supervisor or the RTWC. Use additional pages as needed.

Employee Name:___________________________________ Date of Injury:______________________________________

 

Notes:   Date/time of contact:

Notes:   Date/time of contact:

Notes:   Date/time of contact:

Notes:   Date/time of contact:

Notes:   Date/time of contact:

Notes:   Date/time of contact:

Notes:   Date/time of contact:

 

Sample letter to physician — return-to-work program

Instructions: Send this letter to the treating physician. Attach a blank copy of the “Attending physician’s report: Return-to-work recommendations” or state equivalent form. Also attach a description of the available transitional duty tasks.

Date

Name of physician

Address 1

Address 2

City, State, Zip

 

RE: Return-to-work program

Dear [Name of physician]:

We have implemented a return-to-work program at our company, designed to bring employees back to work as soon as they are physically able, to perform work that is meaningful, without aggravating their injury or illness.

Please complete the attached “Attending physician’s report: Return-to-work recommendations” form and fax it to [RTWC’s fax number].

To assist you in completing the return-to-work form, attached is a list of transitional duty tasks that are currently available.

If you have questions, please call me at [RTWC’s phone number].

Sincerely,

[Name of return-to-work coordinator]

Return-to-work coordinator

 

Attachments

 

Attending physician’s report: Return-to-work recommendations

Patient's last name	First	MI	Date of injury

The following to be completed by the physician
Diagnosis/condition:
I saw and treated this patient on ____________________________________ (date) and based on the above diagnosis/condition: o The patient may return to work with no limitation on ____________________________________ (date) o The patient may return to work on (date) with the following restrictions:
o Sedentary work. Occasionally lifting 10 pounds maximum, with frequent lifting and/or carrying of lighter objects such as file folders, laptop computers and small tools. Although a sedentary job is generally considered one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.	A.  In an eight hour work day patient may:      Stand/walk: o None           o 3-5 hours o 1-3 hours    o 5-8 hours      Sit: o 1-3 hours    o 3-5 hours o 5-8 hours      Drive: o None           o 3-5 hours o 1-3 hours    o 5-8 hours B.  Patient may use hand(s) for repetitive: o Single grasping   o Pushing and pulling o Fine manipulation C.  Patient may use foot/feet for repetitive movement as in operating foot controls: o Yes    o No D.  Patient may:              Not at all   Occasionally   Frequently Bend          o                  o                  o Twist          o                  o                  o Squat         o                  o                  o Climb         o                  o                  o Reach         o                  o                  o
o Light work. Occasionally lifting 20 pounds maximum, with frequent lifting and/or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree or when it involves sitting most of the time with a degree of pushing and pulling of arm and/or leg controls.
o Light-medium work. Occasionally lifting 30 pounds maximum, with frequent lifting and/or carrying of object weighing up to 20 pounds.
o Medium work. Occasionally lifting 50 pounds maximum, with frequent lifting and/or carrying of objects weighing up to 25 pounds.
o Heavy work. Occasionally lifting 100 pounds maximum, with frequent lifting and/or carrying of objects weighing up to 50 pounds.

 

Other restrictions, instructions or prescribed medications:
3. o The above restrictions are in effect until ____________________ (date) or until patient is re-evaluated on _________________________ (date) 4. o Patient is totally incapacitated at this time. Patient will be re-evaluated on__________________________________ (date) 5. o Referred To: o None _________________________________________________________________________________________                                  o Other healthcare professional __________________________________________ (name and specialty) 6. o Return Here ______________________________________________ (date/time)
Physician’s Signature	Date

 

Authorization to release information
I hereby authorize my attending physician and/or hospital to release any information or copies thereof acquired in the course of my examination or treatment for the injury/illness identified above to my employer or my employer’s representative.
Patient’s Signature	Date

 

Sample letter to employee — offer of transitional duty

Instructions: This is a sample letter to the injured or ill employee, that should be sent after the physician’s evaluation is received, clearing the employee to return to work to perform transitional duty.

Send by U.S. mail certified return receipt, or with tracking and signature required.

 

Date

Name of Employee

Address 1

Address 2

City, State Zip

 

Dear [Name of Employee]:

Dr. [Name of Physician] has released you to return to transitional duty, and there is work available that falls within your restrictions.

Please report to [Name of Supervisor of Transitional Duty Work] on [Date] at [Time].

Everyone is looking forward to seeing you back at work.

If you have any questions, please call me at [Phone Number].

 

Sincerely,

[Name of RTWC]

Return-to-work coordinator

 

Employee and supervisor work restriction acknowledgment

Instructions: Once the employee is released by the physician to return to transitional duty, the employee and supervisor should complete this form. Provide copies to the injured worker and their supervisor.

 

Re: Attending physician’s report: Return-to-work recommendations

Employee

I understand, take responsibility for, and acknowledge the limitations placed on me by

Dr. ______________________________________________________ , in the attending physician report dated______________________________________ while I participate in the return-to-work program.

 

Employee’s Name:_________________________________________________________________________

Employee’s Signature __________________________________________ Date________________________

Supervisor

I have read and understand the temporary limitations dated _____________ that have been placed on this employee.

 

Supervisor’s Name:________________________________________________________________________

Supervisor’s Signature ________________________________________ Date_________________________

 

 

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This material is provided for informational purposes only and does not provide any coverage or guarantee loss prevention. The examples in this material are provided as hypothetical and for illustration purposes only. The Hanover Insurance Company and its affiliates and subsidiaries (“The Hanover”) specifically disclaim any warranty or representation that acceptance of any recommendations contained herein will make any premises, or operation safe or in compliance with any law or regulation. By providing this information to you. The Hanover does not assume (and specifically disclaims) any duty, undertaking or responsibility to you. The decision to accept or implement any recommendation(s) or advice contained in this material must be made by you.

171-1088 (03/14)               LC 14-54