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List of Sample Forms

Injury Management

Title Type
Communication Log

• Track communications and activities related to injury/illness claim (e.g. phone calls, submission /receipt of forms/documents, meetings, etc.)

• Different parties may want to keep their own log (e.g. Injury Management Coordinator, worker’s direct Supervisor, etc.)  

• Keep facts of injury/illness claim clear and organized

 MS Word
Letter to Employee

• Give to injured worker if/when medical aid required

• Provides worker with instruction on the documents to bring to treating physician  

• Form should be readily accessible at every worksite/workplace (i.e. provide to worker before leaving site for medical)

 MS Word
Letter to Physician

• Worker brings to physician

• Provides physician with information on company’s injury management program including the availability of modified or alternate duties

 MS Word
Modified or Alternate Work Offer Form

• Employer’s written offer of transitional duties (i.e. modified or alternate work)

• Individualized offer/plan that includes description of the specific duties to be performed under the agreement, the worker’s temporary limitations, hours of work during placement, and length of placement

• Develop offer/plan based on worker’s current medical restrictions, physical limitations, and abilities

 MS Word
Stay-at-Work/Return-to-Work Planning Form

• Worker brings to physician 

• Provides employer (and worker) with worker’s physical limitations and medical restrictions 

• Worker returns completed form to employer the same day (or next scheduled shift)

• Assists in development of Modified or Alternate Work Offer/Return to Work Plan

 MS Word