Return to Work Program - Ministry Advantage

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Modified/Return-to-Work Program 8 Attachment A: Sample Policy Statement Sample Policy Statement 1 (Company name) is committed to providing a safe workplace for our employees. Preventing work related illness and injury is our primary goal. Our early return to work program provides opportunities for an employee who is injured on the job to return to work at full duty. If the injured worker is not physically capable of returning to full duty, the program provides opportunities to perform his or her regular job with modifications or, when available, to perform alternate temporary work that meets the injured worker's physical capabilities. _____________________________________________ Signature of President/CEO/Manager _____________________________________________ Date Sample Policy Statement 2 (Company name) will make every reasonable effort to provide suitable return to work opportunities for every employee who is unable to perform his/her regular duties following a work-related injury. This may include modifying the employee’s regular job or, if available, providing temporary alternate work depending on the employee’s physical abilities. Only work that is considered productive and meaningful to the business shall be considered. Injured workers who are participating in the early return to work program are expected to provide feedback in order to improve the program’s future development. _____________________________________________ Signature of President/CEO/Manager _____________________________________________ Date
Modified/Return-to-Work Program 9 Attachment B: Pre-designation of Physician Form If I have a work-related injury or illness, I choose to be treated by the following medical provider: Name of Doctor, (Please Print) MD, DO, DC, LAC Street Address (Please Print) City State Zip Code Telephone Number ( ) I understand that pre-designating is only available if the following requirements are met: 1. My employer provides group health coverage; 2. The physician I select is my primary care MD or DO who has previously directed my medical treatment; and 3. The physician I select agrees to be my pre-designated physician. Employee Name (Please Print) Employee Signature Date Physician’s Signature Date Source: Institute of Industrial Relations (IIR), University of California at Berkeley, and the Labor Occupational Health Program (LOHP), Center for Occupational and Environmental Health, School of Public Health, University of California at Berkeley and the California Commission on Health and Safety and Workers’ Compensation (CHSWC).
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Return to Work Program - Ministry Advantage

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