Return-to-Work Program

Injury/Illness Management Checklist

Employee Name:_____________________________ Date of Injury/Illness:___________ Employee’s Home Phone #: ____________________

WHEN AN EMPLOYEE HAS REPORTED AN INJURY/ILLNESS THAT REQUIRES MEDICAL ATTENTION, THE FOLLOWING ACTIONS SHOULD BE TAKEN:

ACTION COMPLETED DATE

  1. Initial medical treatment provided by: Dr: ______________________________ ________________ Phone #:______________________________
  2. Received completed supervisor’s report of injury ________________
  3. Submit employer’s First Report of injury to carrier ________________
  4. Contact with employee within 24 hours to give explanation ________________ of WC process
  5. SORM-85 and DWC-73 provided to doctor ________________
  6. Contact doctor’s office regarding RTW program and ________________ provide doctor with copy job description
  7. Meet with Supervisor to identify modified job availability ________________
  8. Obtain copy of doctor’s release (DWC-73) for employee to ________________ perform modified duty.
  9. Send letter to employee by certified mail, offering modified ________________ duty.
  10. Meet with employee and supervisor to discuss modified job ________________
  11. Contact claims adjuster and set up return-to-work date with ________________ employee Adjuster’s name: _____________________ RTW Date: _________________
  12. Employee returns to full duty/modified duty or termination ________________ date
  13. Monitor progress with employee, provider and adjuster ________________

(04/02)