Workers Compensation Work Status Report
I. Introduction
Employee Name: Malcolm Raynor
Employee ID: 594-92-5626
Report Date: June 10, 2050
Report Prepared By: [YOUR NAME]
II. Employee Information
Field | Details |
|---|
Employee Name | Malcolm Raynor |
Employee Contact | malcolm@you.mail |
Job Title | Warehouse Associate |
Department | Logistics |
Supervisor Name | Philip Mitchell |
III. Injury/Illness Details
Field | Details |
|---|
Date of Injury/Illness | May 25, 2050 |
Incident Description | Malcolm Raynor slipped and fell while carrying a heavy box in the warehouse. Immediate first aid was administered, and he was taken to the emergency room for further evaluation. |
Nature of Injury/Illness | Malcolm Raynor sustained a sprained ankle and a minor lower back strain. |
IV. Medical Evaluation
Field | Details |
|---|
Healthcare Provider | Dr. Heidi Bowen |
Provider Contact | heidi@email.com |
Medical Assessment | Dr. Bowen diagnosed the employee with a sprained right ankle and a lower back strain. Treatment included immobilization of the ankle, pain medication, and physical therapy sessions. |
Work Restrictions | No lifting over 10 pounds Limited standing or walking (maximum of 2 hours per shift) Must use an ergonomic chair
|
V. Workplace Accommodation
Field | Details |
|---|
Recommended Accommodations | Provide an adjustable workstation with an ergonomic chair Allow the employee to perform seated tasks for most of his shift Assign light duties that do not require lifting
|
Implementation Plan | Ergonomic chair to be provided by June 15, 2050 Adjust workstation height and layout by June 17, 2050 Assign the employee to inventory management tasks, which are primarily desk-based
|
VI. Return-to-Work Plan
Field | Details |
|---|
Estimated Return-to-Work Date | |
Phased Return Plan | June 20-30, 2050: Part-time (4 hours/day) with light duties July 1-10, 2050: Increased hours (6 hours/day) with continued light duties July 11, 2050, onwards: Full-time with regular duties as tolerated
|
Follow-Up Appointments | June 25, 2050: Follow-up with Dr. Bowen July 5, 2050: Physical therapy session
|
VII. Conclusion
Summary:
Malcolm Raynor sustained a sprained ankle and lower back strain from a workplace incident on May 25, 2050. He has been medically cleared for a phased return to work with specific accommodations. These include limited lifting, restricted standing/walking, and the use of an ergonomic chair.
Next Steps:
To attend a follow-up appointment with Dr. Bowen on June 25, 2050
Employer to provide recommended accommodations by June 17, 2050
HR to monitor the employee's progress and adjust duties as needed
VIII. Contact Information
Field | Details |
|---|
Company Name | [YOUR COMPANY NAME] |
Company Address | [YOUR COMPANY ADDRESS] |
Company Phone | [YOUR COMPANY NUMBER] |
Company Website | [YOUR COMPANY WEBSITE] |
Company Social Media | [YOUR COMPANY SOCIAL MEDIA] |
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