HomeMy WebLinkAbout060 - Return to Work Physicians Release s
A � MI N ISTRATI VE ORDER NO . 60
TO : All Departments October 12 , 1987
FROM : Gary Crutchfield ty anager
SUBJECT : RETURN TO W - PHYSICIAN ' S RELEASE .
The following Administrative Order is effective October 12 , 1987 :
i . PURPOSE : It is in the best interests of the City as an employer
and of its employees to provide a safe work environment , free
of contagious illnesses and conditions detrimental to the health
of employees . Furthermore, it is in the interests of both the
employer and the employee to have reasonable assurance that any
employee who has suffered a serious illness or injury is able to
resume their job duties without risk of harm to themselves or to
their co- workers . The purpose of this Administrative Order
is to provide a means of obtaining reasonable assurance of the
safe return to work of employees who have suffered serious illness
or injury .
H . PROCEDURE :
A . Required Form . In each of the circumstances set forth
in Paragraph B below , an employee will be required to submit
prior to their return to work , a completed PHYSICIAN ' S
RELEASE / RETURN TO WORK FORM . A copy of this form
is attached to this Administrative Order as Exhibit " A " .
This form shall be used by all City departments , It shall
be used in conjunction with the COVER LETTER to the employee' s
physician , a copy of which is attached hereto as Exhibit " B "
and a copy of the individual employee' s job description .
B . Circumstances . The RETURN TO WORK / PHYSICIAN 'S RELEASE
FORM will be required in the following circumstances :
1 . Any illness or injury for which workmen 's compensation
benefits are paid .
2 . Any illness or injury for which LEOFF disability leave
benefits are paid .
3 . Any illness or injury for which an employee is out of
work for five ( 5 ) or more continuous shifts .
4 . When the department head determines the safety of
his / her work force or the individual employee justifies
the physician 's statement , unless restricted by collective
bargaining agreement .
C . Payment of Costs Incurred . In the event an employee is
required under Section B . 3 or B . 4 ( above ) to incur medical
services costs for compliance with Section A ( above ) , which
the employee would not otherwise have incurred , such reasonable
costs will be reimbursed by the City after payment of that
portion covered by the City ' s health benefits program .
D . Distribution to Employees . Each department head shall
be responsible for distributing to all employees within their
department a copy of the COVER LETTER , PHYSICIAN 'S
RELEASE/ RETURN TO WORK FORM , and a copy of the particular
employee's JOB DESCRIPTION . Job descriptions are available
through the personnel office .
CAUTION : Be sure you provide the employee with the most
recently adopted written job description . Department heads
shall instruct their employees that the forms provided should
be kept by them with their medical insurance forms at home
for their use in any of the circumstances outlined in Paragraph
B above . It will be the employee' s responsibility to provide
their physician with the forms and return the completed
PHYSICIAN ' S RELEASE / RETURN TO WORK FORM prior to
being permitted to return to work .
2
v , CITY MANAGER (509) 545-3404 / Scan 726-3404
AWN ,1 P . O. BOX 2939 412 WEST CLARK, PASCO, WASHINGTON 99301
COVER LETTER TO PHYSICIAN 'S RELEASE/ RETURN TO WORK
Dear Doctor :
The City of Pasco Administrative Order No . 60 requires that an employee
who has been absent from work due to a job- incurred sickness or injury
have a PHYSICIAN 'S RELEASE / RETURN TO WORK FORM signed by their
treating physician prior to their return to work .
The purpose of the PHYSICIAN 'S RELEASE / RETURN TO WORK FORM
is to enable the employer to know the employee' s current physical condition ,
what limitations ( if any ) should be placed upon the employee' s work to
avoid reoccurrence or aggravation of the injury or illness, and to enable
the employer to make whatever reasonable accommodations might be necessary
to continue the employee' s employment .
In order for you to complete the attached form , it is necessary that you
READ the attached job description for the employee and question the
employee to your satisfaction as to their actual job duties . The process
assures that you are informed as to the employee' s actual job duties and
that reasonable consideration is given to those duties in determining your
recommendations for job- related limitations or restrictions . THIS PROCESS
PROVIDES BOTH THE PHYSICIAN AND THE CITY WITH THE INFORMATION
THEY NEED TO MAKE INFORMED DECISIONS ,
PLEASE BE ASSURED that the City of Pasco is not attempting by this
procedure to make you the insurer of the employee's physical condition
or to obtain a guarantee that the employee is fit to return to work . In
that regard , THE CITY OF PASCO AGREES NOT TO SUE YOU OR FILE
ANY CLAIM AGAINST YOU FOR ANY LOSS TO THE CITY ARISING FROM
YOUR NEGLIGENCE IN ANSWERING AND COMPLETING THE PHYSICIAN 'S
RELEASE / RETURN TO WORK FORM .
Thank you for your cooperation .
4Vert ours ,
GC : ps ield
encl .
City of Pasco
Physician' s Release/Return to Work
Patient's Name:
(Please type or print) L&I claim # (if applicable)
The undersigned, as the treating physician of the above named City of Pasco employee since
❑ An illness
for ❑ An involuntary physical incapacity (not work related)
Date ❑ An involuntary physical incapacity (work related)
❑ A voluntary physical incapacity
has read the patient/employee' s written job description for the position of
does hereby declare that such patient/employee:
Check appropriate box
• ❑ Is "Fit for Duty" and physically able to return to work on The patient' s
recovery is complete and he/she may return to work without restrictions.
❑ The patient is "Not Fit for Duty" recovery is not yet complete; his/her prognosis is:
❑ The patient is "Not Fit for Duty" but may return to light duty (if any is available); work
should be restricted as follows (be specific as possible) :
until
Name of Doctor - Type or Print Telephone
Signature of Doctor Date
6/18/01