Employment & HR
Return to Work Agreement
Agreement for employee return to work after leave, injury, or disability with accommodations and expectations. Two signers (employer and employee).
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# Return to Work Agreement **Effective Date:** ___________ This Return to Work Agreement ("Agreement") is entered into by and between: **Employer:** ___________ ("Employer") **Employee:** ___________ ("Employee") ## 1. Employee Information **Position/Title:** ___________ **Department:** ___________ **Supervisor:** ___________ **Date of Hire:** ___________ ## 2. Leave Information **Reason for Leave:** ___________ **Leave Start Date:** ___________ **Leave End Date/Return Date:** ___________ **Total Duration of Leave:** ___________ ## 3. Medical Clearance **Medical Clearance Status:** ___________ **Healthcare Provider Name:** ___________ **Clearance Date:** ___________ **Restrictions (if any):** ___________
Fields (39)
effective date
date · required
employer name
text · required
employee name
text · required
position
text · required
department
text · required
supervisor
text · required
hire date
date · required
leave reason
select · required
leave start
date · required
return date
date · required
leave duration
text · required
medical clearance
select · required
provider name
text
clearance date
date
restrictions
textarea
restriction duration
select · required
actual return date
date · required
return schedule
select · required
work location
select · required
returning position
select · required
position details
textarea
modified duties
textarea
return compensation
select · required
accommodations
select · required
accommodation details
textarea
accommodation review
date
transition plan
select · required
transition details
textarea
checkin schedule
select · required
benefits status
select · required
pto status
select · required
seniority
select · required
followup
select · required
drug testing
select · required
performance review
select · required
governing state
select · required
employer signer name
text · required
employer signer title
text · required
employee signer name
text · required
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