Occupational Health Return-to-Work Clearance

Occupational Health Return-to-Work Clearance — Form Fields

This healthcare template includes 10 fields. Submit a return-to-work clearance form after a medical leave, illness, or workplace injury. Free to customize and use on ZenBuild.

• Employee Full Name (text, required)
• Employee Email (email, required)
• Department (text, required)
• Last Day Worked (text, required)
• Return to Work Date (text, required)
• Reason for Leave (dropdown selection, required) — options: Illness, Injury (work-related), Injury (non-work), Surgery, Mental health, Family medical leave, Other
• Return Status (multiple choice, required) — options: Full duty, Modified duty with restrictions, Graduated return
• Work Restrictions (if any) (long text, optional)
• Treating Physician Name (text, required)
• Physician Clearance Letter (file upload, required)