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 路 required
employer name
text 路 required
employee name
text 路 required
position
text 路 required
department
text 路 required
supervisor
text 路 required
hire date
date 路 required
leave reason
select 路 required
leave start
date 路 required
return date
date 路 required
leave duration
text 路 required
medical clearance
select 路 required
provider name
text
clearance date
date
restrictions
textarea
restriction duration
select 路 required
actual return date
date 路 required
return schedule
select 路 required
work location
select 路 required
returning position
select 路 required
position details
textarea
modified duties
textarea
return compensation
select 路 required
accommodations
select 路 required
accommodation details
textarea
accommodation review
date
transition plan
select 路 required
transition details
textarea
checkin schedule
select 路 required
benefits status
select 路 required
pto status
select 路 required
seniority
select 路 required
followup
select 路 required
drug testing
select 路 required
performance review
select 路 required
governing state
select 路 required
employer signer name
text 路 required
employer signer title
text 路 required
employee signer name
text 路 required
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