WSV_for_Non-Work_Injuries.pdf
PDF 225 KB Posted
- Attached to
- City Wide Occupational Health Services
- Solicitation number
- 240140
- Issued by
- Pima County, Tucson City, Arizona
About this file
This is a Work Status Verification form from the City of Tucson's Human Resources Leaves & Accessibility department, located in Tucson, Arizona. The document is a medical clearance form designed to verify an employee's ability to return to work following a medical absence or with potential work restrictions. The form provides a structured approach for physicians to document an employee's medical status, including options for full return to work, modified duty, restrictions on physical activities, and estimated return dates.
The form allows for detailed medical documentation, including specific work limitations such as restricted lifting, pushing/pulling, reaching, hand usage, walking, standing, or sitting. Physicians can specify maximum weight limits, restricted movements, and other unique work constraints. The form is used in accordance with Administrative Directive 2.01-7 and requires completion by both Human Resources and the examining physician, with sections for medical clearance type, examination details, and specific work restrictions or limitations.
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Text version
City Of Tucson Human Resources Leaves & Accessibility PO Box 27210, Tucson AZ 85726-7210 Phone: (520) 791-2619 / Fax: (520) 791-4941
WORK STATUS VERIFICATION
EMPLOYEE INFORMATION
TO BE COMPLETED BY HUMAN RESOURCES
NAME: Last, First MI BIRTH DATE EMPLOYEE #
POSITION
DEPARTMENT DIVISION
PHYSICIAN’S PRINTED NAME PHYSICIAN’S SIGNATURE DATE
TO BE COMPLETED BY PHYSICIAN
Medical Clearance Required By:
City Physician
Employee’s Physician
Date of Medical Examination: Location of Medical Examination:
mm/dd/yy
MEDICAL CLEARANCE TO RETURN TO WORK
Employee unable to work. Expected return to work date is
Employee may return to work without restrictions: Immediately On date:
Employee may return to modified duty on date with the following restrictions until (date)
Employee is expected to return to full duty: Estimated Date
No driving No equipment operation Reduced hours hrs./days Other – Explain Below
1. ⃣ Restricted lifting/carrying (maximum weight in pounds)
2. ⃣ Restricted pushing/pulling (maximum weight in pounds)
3. ⃣ Restricted Reaching Above Chest ⃣ Overhead ⃣ Away from body
4. ⃣ Restricted one handed duty: No use of ⃣ Right Hand ⃣ Left Hand
5. ⃣ Restricted walking ⃣ Standing ⃣ Sitting ⃣ Weight Bearing (describe)
6. ⃣ Other Restrictions/Clarification of Restrictions (describe below)
This form is used when an employee is required to provide a medical clearance or detailed work restrictions PRIOR to returning to work pursuant to Administrative Directive 2.01-7.
File details come from the government source that posted it. Updated .