Free Workers Compensation Work Status Report Template

Workers Compensation Work Status Report

I. Introduction

Employee Name: Malcolm Raynor
Employee ID: 594-92-5626
Report Date: June 10, 2050
Report Prepared By: [YOUR NAME]

II. Employee Information

Field	Details
Employee Name	Malcolm Raynor
Employee Contact	malcolm@you.mail
Job Title	Warehouse Associate
Department	Logistics
Supervisor Name	Philip Mitchell

III. Injury/Illness Details

Field	Details
Date of Injury/Illness	May 25, 2050
Incident Description	Malcolm Raynor slipped and fell while carrying a heavy box in the warehouse. Immediate first aid was administered, and he was taken to the emergency room for further evaluation.
Nature of Injury/Illness	Malcolm Raynor sustained a sprained ankle and a minor lower back strain.

IV. Medical Evaluation

Field	Details
Healthcare Provider	Dr. Heidi Bowen
Provider Contact	heidi@email.com
Medical Assessment	Dr. Bowen diagnosed the employee with a sprained right ankle and a lower back strain. Treatment included immobilization of the ankle, pain medication, and physical therapy sessions.
Work Restrictions	No lifting over 10 pounds Limited standing or walking (maximum of 2 hours per shift) Must use an ergonomic chair

V. Workplace Accommodation

Field	Details
Recommended Accommodations	Provide an adjustable workstation with an ergonomic chair Allow the employee to perform seated tasks for most of his shift Assign light duties that do not require lifting
Implementation Plan	Ergonomic chair to be provided by June 15, 2050 Adjust workstation height and layout by June 17, 2050 Assign the employee to inventory management tasks, which are primarily desk-based

VI. Return-to-Work Plan

Field	Details
Estimated Return-to-Work Date	June 20, 2050
Phased Return Plan	June 20-30, 2050: Part-time (4 hours/day) with light duties July 1-10, 2050: Increased hours (6 hours/day) with continued light duties July 11, 2050, onwards: Full-time with regular duties as tolerated
Follow-Up Appointments	June 25, 2050: Follow-up with Dr. Bowen July 5, 2050: Physical therapy session

VII. Conclusion

Summary:
Malcolm Raynor sustained a sprained ankle and lower back strain from a workplace incident on May 25, 2050. He has been medically cleared for a phased return to work with specific accommodations. These include limited lifting, restricted standing/walking, and the use of an ergonomic chair.

Next Steps:

To attend a follow-up appointment with Dr. Bowen on June 25, 2050
Employer to provide recommended accommodations by June 17, 2050
HR to monitor the employee's progress and adjust duties as needed

VIII. Contact Information

Field	Details
Company Name	[YOUR COMPANY NAME]
Company Address	[YOUR COMPANY ADDRESS]
Company Phone	[YOUR COMPANY NUMBER]
Company Website	[YOUR COMPANY WEBSITE]
Company Social Media	[YOUR COMPANY SOCIAL MEDIA]

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