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1. Doctor's Information: Complete details of the issuing physician including name, medical practice address, contact information, and professional credentials
2. Patient Information: Patient's full name, date of birth, and address (as required for proper identification)
3. Date of Examination: The date when the medical assessment was performed
4. Work Restriction Period: Clear specification of the duration for which the restrictions apply, including start and end dates
5. Specific Work Restrictions: Detailed description of activities that the patient cannot perform or must perform with limitations
6. Medical Certification: Official statement certifying that the restrictions are medically necessary
7. Doctor's Signature: Legal signature of the issuing physician with date and official stamp
1. Permitted Activities: List of work activities the patient can safely perform, included when partial work capability exists
2. Required Workplace Accommodations: Specific modifications or accommodations needed in the workplace, included when relevant
3. Follow-up Requirements: Information about necessary follow-up examinations or assessments, included when ongoing monitoring is needed
4. Emergency Protocols: Special instructions for handling emergency situations related to the medical condition, included for specific health conditions
5. Gradual Return Plan: Structured plan for gradually increasing work activities, included when a phased return to work is recommended
1. Activity Restriction Chart: Detailed chart showing specific activities and their respective limitations (e.g., lifting weights, standing duration)
2. Medical Documentation: Copies of relevant medical test results or specialist opinions (only if required and with patient consent)
3. Workplace Assessment Form: Form detailing specific workplace conditions and necessary modifications
Medical Condition
Essential Job Functions
Temporary Disability
Permanent Disability
Workplace Accommodation
Modified Duty
Regular Duty
Physical Limitations
Working Hours
Rest Periods
Occupational Health Provider
Follow-up Examination
Gradual Return to Work
Light Duty
Maximum Lifting Capacity
Restricted Activities
Work Environment
Safety Measures
Medical Review
Treatment Plan
Work Capacity
Duration of Restrictions
Professional Medical Opinion
Workplace Hazards
Healthcare
Manufacturing
Construction
Retail
Hospitality
Information Technology
Education
Transportation
Logistics
Financial Services
Public Sector
Mining
Agriculture
Energy
Telecommunications
Human Resources
Occupational Health and Safety
Operations Management
Legal and Compliance
Employee Relations
Workplace Services
Facilities Management
Production Management
Risk Management
Benefits Administration
Human Resources Manager
Occupational Health Officer
Health and Safety Coordinator
Line Manager
Department Supervisor
Factory Manager
Office Manager
Operations Director
Workplace Safety Specialist
Employee Relations Manager
Disability Coordinator
Return to Work Coordinator
Production Supervisor
Site Manager
Compliance Officer
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