Return to Work Plan Monitoring Form

Employers and workers, use this form to assist in tracking progress throughout the RTW plan.

To be completed with worker preset.

Worker Name(Required)

First Last

Pre-injury Supervisor(Required)

First Last

Modified Work Supervisor (if different)

First Last

Review Period Date From(Required)

Review Period Date To(Required)

Hours Worked (attendance)

Week

Mon

Tues

Wed

Thurs

Fri

Sat

Duties Assigned

(list the work assigned during the review period)

Comments and/or Concerns from

Worker

Employer

Is the modified work or RTW plan assisting in accomplishing the goals?

Yes

If no, why?

Are there any other suggestions on how to improve the plan?

Next Steps

Revising existing plan

Continuing with plan

Closing RTW plan – RTW goal achieved

Next Follow-up Date (if needed):

Workers Name(Required)

First Last

Date(Required)

Signature(Required)

Supervisor/HR Name(Required)

First Last

Date(Required)

Signature(Required)