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Metro Home Building Centre – Staff
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  • Forms
    • Section 02
      • Disciplinary Warning Notice Form
      • Manager Safety Performance Review
      • Supervisor Safety Performance Review
      • Employee Safety Performance Review
    • Section 04
      • Bomb Threat / Anonymous Telephone Call Record
      • Fall Arrest System Inspection Form
      • Emergency Response Plan for Employees Requiring Accommodations
      • Harassment Incident Report Form
      • Hazard Report Form
      • Hot Work Permit
      • Housekeeping Inspection Form
      • Illness/Injury Reporting Form
      • Lockout Add
      • Lockout Removal
      • Non-Routine Work Form
      • Violence Incident Report Form
      • Work Refusal Form
      • Spill Report Form
    • Section 05
      • Annual Safety Committee Meeting Schedule
      • Safety Committee Meeting Minutes
      • Safety Committees Recommendations to Employer Form
    • Section 06
      • Orientation Checklist
      • Employee Information Form
      • Direct Deposit Agreement Form
      • TD1 – Personal Tax Credits Return
    • Section 07
      • First Aid Treatment Record
      • Refusal of Treatment or Refusal to be Transported to The Hospital Statement
    • Section 08
      • Ladder Inspection Checklist
      • Quarterly Workplace Inspection Checklist
      • Workplace Inspection Report Form
    • Section 10
      • Accident / Incident Investigation Report
      • Accident / Incident Investigation Employee’s Statement
      • Accident / Incident Investigation Witness Statement
    • Section 12
      • Return to Work Plan Monitoring Form
      • Exit Program Form – Injury Management and Return to Work
      • Return to Work Plan
  • Benefits
  • Online Training
  • Metro Home
  • Staff Home
  • Safety
    • Policies
    • Government Regulations
    • Meeting Minutes
    • Inspection Reports
    • Inspection Certificates
    • Guides
    • Posters
    • Responsibilities
  • Vacation Tracker
  • Vacation Board
  • Forms
    • Section 02
      • Disciplinary Warning Notice Form
      • Manager Safety Performance Review
      • Supervisor Safety Performance Review
      • Employee Safety Performance Review
    • Section 04
      • Bomb Threat / Anonymous Telephone Call Record
      • Fall Arrest System Inspection Form
      • Emergency Response Plan for Employees Requiring Accommodations
      • Harassment Incident Report Form
      • Hazard Report Form
      • Hot Work Permit
      • Housekeeping Inspection Form
      • Illness/Injury Reporting Form
      • Lockout Add
      • Lockout Removal
      • Non-Routine Work Form
      • Violence Incident Report Form
      • Work Refusal Form
      • Spill Report Form
    • Section 05
      • Annual Safety Committee Meeting Schedule
      • Safety Committee Meeting Minutes
      • Safety Committees Recommendations to Employer Form
    • Section 06
      • Orientation Checklist
      • Employee Information Form
      • Direct Deposit Agreement Form
      • TD1 – Personal Tax Credits Return
    • Section 07
      • First Aid Treatment Record
      • Refusal of Treatment or Refusal to be Transported to The Hospital Statement
    • Section 08
      • Ladder Inspection Checklist
      • Quarterly Workplace Inspection Checklist
      • Workplace Inspection Report Form
    • Section 10
      • Accident / Incident Investigation Report
      • Accident / Incident Investigation Employee’s Statement
      • Accident / Incident Investigation Witness Statement
    • Section 12
      • Return to Work Plan Monitoring Form
      • Exit Program Form – Injury Management and Return to Work
      • Return to Work Plan
  • Benefits
  • Online Training

Return to Work Plan

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  2. Return to Work Plan

Return to Work Plan

To be completed with worker preset.
Employee Name(Required)
Pre-injury Supervisor(Required)
Modified Work Supervisor (if different)
Effective Date(Required)
Anticipated End Date(Required)
Objective of Return to Work Plan
(choose one)
Hours (include progression schedule, if applicable)
Work Week
Mon
Tues
Wed
Thu
Fri
Sat
Comments
 

Monitoring/review (outline schedule for regular monitoring and review)

Follow-up meeting with
Date
Time
:

Signatures: By signing this Return to Work plan we confirm our participation in the development of the plan, that we understand our roles in the implementation and monitoring of the plan and agree to actively participate as outlined above.

Date(Required)
Date(Required)
Metro Home Building Centre - Staff
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