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Please ask the Physician to complete during exam. IT IS YOUR RESPONSIBILITY TO RETURN THE NEEDED PAPERWORK TO YOUR SCHOOL CONTACT OR SHERRY STRATTON!!  \nPlease RETURN the Work Restrictions Checklist to your school secretary or to Sherry Stratton within 24 hours of treatment of this injury.  \nPLEASE NOTE: SOME PHYSICIAN OFFICES HAVE THEIR OWN WORK STATUS FORMS. IF SO, BRING THIS FORM TO YOUR SCHOOL SECRETARY, SUPERVISOR OR SHERRY STRATTON WITHIN 24 HOURS OF THE  \nTREATMENT.  \nWe look forward to your return. If you have any questions, please do not hesitate to contact me.  \n\n|  |\n| --- |\n|  |\n\nRTW Letter to Physician  \nWork Restrictions Checklist  \nWarren County Public Schools 303 Lovers Lane  \nBowling Green, KY 42103 270-781-5150  \nDate:  \nAttn:  \nSubject:  \nDate ofBirth:  \nDear Healthcare Provider:  \nYou are treating a valuable employee of Warren County Public Schools. We have implemented a RECOVERY-AT-WORK PROGRAM to help injured workers with their recovery and rehabilitation and to assist in the transition to a return to full duty employment.  \nPlease submit the billing to KEMI, PO Box 4208, Clinton, IA 52733-4208. Please contact KEMI for authorization of referrals to specialist and procedure requests. They can be reached at 800-640-5364.  \nWe would like to work with you and your patient to find a temporary, transitional position that will assure your patient’s safe return to work. Warren County Public Schools will attempt to modify the employee’s job to meet medical restrictions that maybe assigned.  \nThank you for your participation in the efforts to return Warren County Public Schools employees to a safe and productive workplace and on the road to recovery from their injury.  \nSincerely,  \nSherry Stratton Employee Benefits 270-781-5150  \nRETURN TO WORK AUTHORIZATION FORM  \nWarren County Public Schools has a light duty and transitional work program that provides temporary jobs that injured employees should be able to safely perform during their recovery periods. Completion of this form will allow us to identify an appropriate assignment for this employee. Thank you for your cooperation and prompt response.  \nDate   Employee’s Name   DOB    \nDiagnosis   Return to work date (regular duty)  Return to work date (light duty)  \n Unable to work From   To    Return to Clinic on   Referral:  \n Doctor   Physical therapy  Work Restrictions apply to:  Work  Home  Leisure  \nDuring the applicable workday, this employee can:  \n Sit   hours  Stand   hours  Walk   hours  \nFor Work Day reference: “occasionally”= 1-33%. “frequently”= 34-66%, & “continuously” = 67-100%.  \n\n| Employee Can | Never | Occasionally | Frequently | Continuously |\n| --- | --- | --- | --- | --- |\n| Lift and carry |  |  |  |  |\n| Up to 10 pounds |  |  |  |  |\n| 11-25 pounds |  |  |  |  |\n| 26-35 pounds |  |  |  |  |\n| 36-50 pounds |  |  |  |  |\n| 51-75 pounds |  |  |  |  |\n| 76-100 pounds |  |  |  |  |\n| Reach above shoulder level |  |  |  |  |\n| Push/Pull |  |  |  |  |\n| Climb |  |  |  |  |\n| Squat/Kneel |  |  |  |  |\n| Bend/Stoop/Crouch |  |  |  |  |\n| Twist upper body |  |  |  |  |\n| HEALTHCARE PROVIDER’S PRINTED NAME  CLINIC NAME   |  |  |  |  |","cbCais6NldysmEu7","https://ap.wps.com/l/cbCais6NldysmEu7","pdf",705287,"English","# Injury Recovery-At-Work Letter Packet\n## RTW Letter to Physician\n## Work Restrictions Checklist\n## Return to Work Authorization Form","[{\"question\":\"What documents should the injured employee give to the attending physician?\",\"answer\":\"The packet directs the injured employee to take the RTW Letter to Physician and the Work Restrictions Checklist to the attending physician for completion during the exam.\"},{\"question\":\"How quickly must the completed paperwork be returned after treatment?\",\"answer\":\"The Work Restrictions Checklist must be returned to the school secretary or Sherry Stratton within 24 hours of treatment of the injury. If the physician has its own work status forms, those should be brought back within 24 hours as well.\"},{\"question\":\"How does the Return to Work Authorization Form help the school place the employee?\",\"answer\":\"The form collects employee identification, diagnosis, and return-to-work dates, enabling the school to identify an appropriate temporary transitional or light duty assignment based on medical restrictions.\"}]","Warren County Board of Education Injury Recovery-At-Work Letter Packet | PDF",1789502553]