____ _____ ____ _____ _____ ___

__________

________
___ .

____
_____ _____ _____ ____ ___ ____ _

Medical Record#:

Injury On Dtty (IOD) Attending Physician Form Front Desk lrltloIs: 1(T Date: In: TIme Out:

L( 3O

To be completed by Employee) EMPLOYEE NAME DATE OF BIRTH: DATE OF INJURY: #: TIME 0 INJURY: SUPERVISOR NAME:
__________ ____________

i_HOME #:

WORK

#:______

________ _______

_______

(To e completed by Treating Physician)

DESCRIPTION OF INJURY: ASSESSMENT/DIAGNOSIS:_______ ______ is condition claImed and compatible to be ork relat ed?es ID No Are known pie-existing or other cpns confr illlo n 1 utlng? 0 YeNo Treatment Rendered:

L1Y

MEDICATIONS Prescribed:

Narcotic Medico on

Other Medication

List Medication(s) & Frequency:

ID Do not take while working UNABLE TO WORK _JLIMITEDIIRANSITIONAL .4LREWRN TO REGULAR DUTY

._DISCHARGE FROM CARE/MMI

_PERMANENT RESTRICTIONS

not take wh le driving to and from work ID Do not take while driving for Personal Business Use RETUR TO WORK OUTLINE UPPER XTREMITY BACK _No use of Injured hand/arm __SItting job only _Nc repetitive overhead work _Alternate sit/stand _N lift/push/pull over lbs. _May stand/walk up to his/day N repetitive/heavy gripping _No repetitive stoop/bend/twist _N use of vibrating tools _May stoo repetitive/outstretched arm use _Welght pJbend/lwlst_tlmes/hour limit jbs.

RELEASED TO REGULAR DUTY: FOLLOW UP APPT. REQUIRED REFERRAL TO SPECIALTY:

IP 12{

::

LOWER EXTREMITY ng Job with loot/leg elevated rnaie sit/stand. may walk rt distances squatting or kneeling ATE FOR LIMITED DUTY: IDAS NEEDED

OTHER _Keep dressing clean/dry _Injury prohIbits driving while at work _No use ot hazardous machInery _Medicotions may cause drowsiness END DATE FOR LIMITED DUTY:

YES a NO

DATE: -J_._.......J

TIME: (TPA
to

REFERRAL TO PHYSICAL THERAPY: REFERRAL TO DIAGNOSTIC Comments: Physician Signature: TESTG*

make referral)

jjZ1 ( Y[v I

(TM to make referral)

(TM to make referral)

FORM TO BE COMPLETE NS4N B. TREATING PH(SICIAN OR DESIGNEE. FAX COMPLETED COPY TO TPA A (94)566-341s and 1vlsion OSHAHIS/HER nator at coordi PLEASE GIVE EMPLOYEE COPY OF TUI FORM TO RETURN TO SUPERVISOR. UPON DISCHARGE FROM MEDICAL FACIL SUPERVISOR/OSHA REP FOR RETURN TO WORK ITY anf IF SPECIALTY CARE IS NEEDED, EMPLOYEE MUST MAKE IMME DIATE CONTACT W1TH INSTRUCtIONS AND TPA FOR FOLLOW-UP CARE iNSTRUCT1ONS Form Revised as of 7/23/10