Work Release Form

Work Release Form

The work release form is a document that is used by medical personnel to inform an employer whether or not an employee is unable to return to work as result of illness or injury. If the employee is now able to return to work in a limited capacity, the physician or nurse, will check one of the boxes, if applicable and possibly include notes that will inform the employer that they must assist the employee in working in a safe, physical capacity so as to avoid further illness or physical injury.

How to Write

Step 1 – Download in Adobe PDF (.pdf).

Step 2 – The Doctor or Nurse must provide the following information:

  • Verify that the employee/patient has been seen in the medical facility by entering the employee/patient’s name into the first line provided on the form
  • Enter the date in which the patient/employee was seen
  • Check the box if the patient/employee has medical permission to return to the work site
  • Enter the date that the Physician feels that the patient/employee would be physically safe and/or not contagious to others
  • AND
  • If the employee may return to work, but work activity must be restricted, the physician or nurse must check one or more of the following boxes, to provide a better understanding to the employer regarding exactly what work activities the employee is capable of accomplishing during the healing process:
  • None
  • No heavy lifting ( enter the number of pounds that the patient/employee must not exceed in lifting)
  • No prolonged standing
  • Desk work only
  • Other – the physician or nurse must describe any other restriction in the lines provided in the “Notes” at the bottom of the form

Step 3 – Ending of Medical Restrictions –

  •  Enter the date in which the restrictions would no longer be necessary
  • The employer must heed the advice of the section titled “Be Advised”

Step 4 – Signature of Medical Professional –

  • Submit the signature of either the physician or his/her nurse