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Attn: Alisha Massarini HR-WC/FFD Asst

2700 Post Oak Blvd, Ste. 1800


Houston, TX 77056
(713) 624-8688 Office
(713) 803-1256 Confidential Fax
Alisha.Massarini@AirLiquide.com

Required
Return-to-Work Release Form
PART 1: To Be Completed by Employee (Please Type or Print.)
Name: (First, Middle Initial, Last)
Position Title:
Supervisor:

Business Entity & Department:

Date Leave Commenced:

Date of Planned Return to Work:

Signature:

Date:

PART II: To Be Completed by Employees Health Care Provider


Physicians Name (please print):
Address:
City:

State:

Zip:

Area of Specialty:
Phone:

Fax:

E-mail:

NOTE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of
employees or their family members. In order to comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information.
Genetic information, as defined by GINA, includes an individuals family medical history, the results of an individuals or family members genetic tests, the fact that an individual or an
individuals family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individuals family member or an embryo lawfully held by
an individual or family member receiving assistive reproductive services.

I certify that I have reviewed the job description that includes the physical demands of the above named employees position and
he/she:
is NOT able to return to work. Possible release date: ______________________________
is able to return to work on ____________________________ (Date) with:
No restrictions
With the following restrictions, please be specific:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
__________________________________________________________________

Revised September 2013

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Functional Capabilities:
Please complete the applicable portion of this section based on your most recent clinical assessment. In a general workplace
environment the patient is able to:
0

Number of Hours Per Work Shift


12
34
56
78+

1. Sitting
2. Standing
3. Walking
4. Bending Over
5. Twisting
6. Climbing
7. Reaching above
shoulder level
8. Crouching/Stooping
9. Kneeling
10. Balancing
11. Pushing & Pulling
12. Repetitive Use of Foot Control
A. Right Foot Only
B. Left Foot Only
C. Both Feet
12. Repetitive Use of Hands
A. Right Hand Only
B. Left Hand Only
C. Both Hands

Number of Hours Per Work Shift


12
34
56
78+

14. Grasping
A. Simple/Light
1. Right Hand Only
2. Left Hand Only
3. Both Hands
B. Firm/Strong
1. Right Hand Only
2. Left Hand Only
3. Both Hands
15. Fine Finger Dexterity
A. Right Hand Only
B. Left Hand Only
C. Both Hands
16. Use of Head and Neck in:
A. Static Position
B. Twisting
C. Looking Up
D. Looking Down

Never
0% of Time

Occasionally
1-33% of Time

Frequently
34-66% of Time

Continually
67-100% of Time

17. Lifting or carrying


A. Up to 10 lbs
B. 11 20 lbs
C. 21 50 lbs
D. 51 100 lbs
E. 100 + lbs
18. Frequency of interpersonal relationships necessary to
perform the job
19. Frequency of stressful situations necessary to perform
the job

In the course of performing the job, the employee is


required to perform the following functions or is subject to
the following environmental factors. Is the employee able
to:

YES

20. Drive cars, trucks, forklifts and/or other equipment


21. Be around moving equipment and/or machinery
22. Walk on uneven ground

NO

YES
23. Be exposed to dust, gas, or
fumes?
If yes, is the employee
required to wear a
respirator?
24. Be exposed to marked
changes in temperature or
humidity
25. Can the employee work
overtime?

Additional Comments:

Physicians Signature:

Date:

Part III: To Be Completed by Human Resources


Revised September 2013

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NO

Received By:

Date Received:

LAC Approval:

Date Received:

Revised September 2013

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