Employee Name

[EMPLOYEE'S NAME]

Employee Contact

[EMPLOYEE'S EMAIL]

Job Title

Warehouse Associate

Department

Logistics

Supervisor Name

[SUPERVISOR'S NAME]

Date of Injury/Illness

May 25, 2050

Incident Description

[EMPLOYEE'S NAME] 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

[EMPLOYEE'S NAME] sustained a sprained ankle and a minor lower back strain.

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 ergonomic chair

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

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

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]