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Return To Work Medical Evaluation Form

Return To Work Medical Evaluation Form Template for Philippines

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Key Requirements PROMPT example:

Return To Work Medical Evaluation Form

"I need a Return To Work Medical Evaluation Form for our manufacturing facility in Manila, specifically designed for employees returning from extended medical leave due to workplace injuries, with extra emphasis on physical capacity evaluation and gradual return-to-work protocols."

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Document background
The Return To Work Medical Evaluation Form is a crucial document used in Philippine workplaces to ensure safe and appropriate return of employees following medical leaves. This form is mandated under various Philippine labor regulations, including DOLE Department Order No. 73-05 and Republic Act No. 11058, which establish requirements for workplace safety and health programs. It becomes necessary when employees resume work after sick leave, injury, surgery, quarantine, or other medical-related absences. The document captures essential medical evaluations, work capability assessments, and any required workplace modifications, while ensuring compliance with the Data Privacy Act of 2012 for handling sensitive medical information. The form has gained additional significance with the integration of COVID-19 protocols and serves as a legal protection for both employers and employees in managing return-to-work scenarios.
Suggested Sections

1. Employee Information: Basic identification details including name, employee ID, department, position, and contact information

2. Reason for Evaluation: Specification of why the employee requires return-to-work clearance (e.g., illness, injury, surgery, quarantine)

3. Leave Information: Details of the employee's leave period, including start and end dates

4. Medical History: Summary of the relevant medical condition or injury that led to the leave

5. Current Health Status: Assessment of the employee's present health condition and symptoms

6. Physical Examination Findings: Results of the current physical examination by the evaluating physician

7. Fitness Assessment: Evaluation of the employee's ability to return to work and perform job duties

8. Work Modifications: Any required workplace adjustments or restrictions

9. Medical Certification: Official declaration by the examining physician regarding return-to-work clearance

10. Authorization and Signatures: Signatures of the examining physician, employee, and relevant authorities

Optional Sections

1. COVID-19 Assessment: Additional evaluation specific to COVID-19 risks and protocols, required if the leave was related to COVID-19 or during high-risk periods

2. Specialist Referral Notes: Information from specialist consultations, needed when the employee's condition required specialized medical care

3. Functional Capacity Evaluation: Detailed assessment of physical capabilities, required for returns from serious injuries or extended medical leaves

4. Mental Health Assessment: Evaluation of psychological readiness to return to work, needed for stress-related or mental health leaves

5. Laboratory Test Results: Relevant medical test results, required when specific test results are needed to clear return to work

6. Vaccination Status: Documentation of relevant vaccinations, particularly important during pandemic conditions

Suggested Schedules

1. Medical Examination Checklist: Standardized checklist of physical examination components to be completed by the physician

2. Job Physical Requirements: Detailed list of physical requirements for the employee's specific job role

3. Prescribed Medications List: List of current medications that may affect work performance or safety

4. Follow-up Schedule: Timeline for required follow-up evaluations or monitoring

5. Work Modification Plan: Detailed plan for implementing any required workplace adjustments or restrictions

Authors

Alex Denne

Head of Growth (Open Source Law) @ 抖阴短视频 | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co
Relevant legal definitions































Clauses




















Relevant Industries

Healthcare

Manufacturing

Construction

Mining

Information Technology

Banking and Finance

Education

Retail

Transportation

Hospitality

Government Services

Business Process Outsourcing

Agriculture

Energy

Telecommunications

Relevant Teams

Human Resources

Occupational Health and Safety

Medical Services

Legal and Compliance

Risk Management

Employee Relations

Benefits Administration

Operations

Health, Safety and Environment

Workplace Services

Relevant Roles

HR Manager

Occupational Health Physician

Safety Officer

Compliance Officer

Risk Manager

Employee Relations Manager

Medical Director

Company Nurse

HR Business Partner

Occupational Health and Safety Manager

Benefits Administrator

Leave Management Specialist

Workplace Health Coordinator

HR Operations Manager

Medical Compliance Officer

Industries







Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks, 聽Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination, 聽Severance Pay, Governing Law, Entire Agreemen

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