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Return to work form template

Clear an employee to come back after illness or injury: the provider’s work status, any restrictions and how long they last, and the return date, with no diagnosis.

21 questions · about 5 min · logic · file upload · e-signature

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Page 1 of 2

Your name (required)

Job title (required)

Department

First day of leave (required)

Type of leave (required)

Job description

Optional. Helps your provider judge the essential duties. HR can attach it instead.

Click or drop a file here

PDF, Word, images · up to 10 MB

How will your provider give the release? (required)

What you get back

Every response lands in your results the moment it is sent. Turn on email notifications and each one arrives like this, and the same answers become a row in your spreadsheet.

From PulseFormCreator

Subject New response to Return to work release

Your name
Tomasz Nowak
Job title
Delivery driver
Department
Logistics
First day of leave
2026-08-18
Type of leave
Own illness or injury
How will your provider give the release?
My provider fills in the next section

and 10 more answers

A sample email with made-up answers.
submitted_atYour nameJob titleDepartmentFirst day of leaveType of leave
2026-09-22T09:41:00.000ZTomasz NowakDelivery driverLogistics2026-08-18Own illness or injury

The first 6 of 31 columns. Export to CSV or Excel, or send each response to Google Sheets, Notion, Airtable, Slack or a webhook as it arrives, all on the free plan. The answers above are made up.

What this form asks, and why

The last column shows how many of the 23 real return to work forms we read ask the same thing.

Question Why it is there Real forms
Your name Required Whose release this is, asked on 22 of 23 forms. 22 of 23 forms
Job title Required The provider judges fitness against this job. 12 of 23 forms
Department Optional. Routes the release to the right HR contact. 8 of 23 forms
First day of leave Required Defines the leave the release covers. 12 of 23 forms
Type of leave Required An injury at work brings a claim number with it. 5 of 23 forms
Workers’ compensation claim number Only when “Type of leave” is Injury at work Shown only for an injury at work, so the release joins the claim. 1 of 23 forms
Job description Optional. Lets the provider judge the essential duties; 3 of 23 forms attach one. 3 of 23 forms
How will your provider give the release? Required Many providers have their own release. Either way counts. Our own recommendation
Your provider’s signed release Required Only when “How will your provider give the release?” is I will upload my provider’s own signed release Shown instead of the provider section. Our own recommendation
Work status Required The decision HR acts on, in the three options 10 of 23 forms use. 10 of 23 forms
Date the employee can return, or is expected to Required Asked on 18 of 23 forms. 18 of 23 forms
Can the employee perform the essential functions of their job? Required Only when “Work status” is not Not yet released The fitness-for-duty question. Hidden when not yet released. 7 of 23 forms
Restrictions Required Only when “Work status” is Released with restrictions Shown only for a release with restrictions. 11 of 23 forms
The restrictions are Required Only when “Work status” is Released with restrictions Tells HR whether to plan a review or a lasting change. 6 of 23 forms
Restrictions apply until Required Only when “Work status” is Released with restrictions and “The restrictions are” is Temporary The date to check again. 6 of 23 forms
Next appointment or review date Optional: when the release will be updated. 6 of 23 forms
Could any medication affect safety at work, such as driving or using machinery? Matters for driving and machinery. It asks about the effect, not the medicine. 6 of 23 forms
Provider’s name and practice Required So HR can check the release is real. 10 of 23 forms
Provider’s phone number Required The number HR calls to verify it. 10 of 23 forms
Provider’s signature Required Every US form we read carries one. 15 of 23 forms
Employee’s signature Optional: the employee has seen what the provider wrote. 9 of 23 forms

What we left out

  • Diagnosis. 6 of 23 forms ask. HR can act on work status and restrictions alone, and US law limits questions to ability to work.
  • An hours-per-activity grid. 5 of 23 forms grid hours standing or sitting and weights lifted. One restrictions box and the job description cover the same ground on a phone.
  • A general health-information consent. On 3 of 23 forms. The employee chooses what the provider sends, and the note says what not to.

What 23 real return to work forms ask

In September 2026 we read 23 return to work forms that organisations use today (US 15, UK 7, Ireland 1) and recorded every field. This is how often each one appears. It is part of the Form Field Index.

  1. The employee's name 22 of 23 (22 of 23 forms)
  2. Date the employee can or did return 18 of 23 (18 of 23 forms)
  3. Health care provider's signature 15 of 23 (15 of 23 forms)
  4. First day of absence or date leave began 12 of 23 (12 of 23 forms)
  5. Job title or position 12 of 23 (12 of 23 forms)
  6. Work restrictions 11 of 23 (11 of 23 forms)
  7. Full duty, restricted or not released 10 of 23 (10 of 23 forms)
  8. Provider’s name and contact 10 of 23 (10 of 23 forms)
  9. Employee's signature 9 of 23 (9 of 23 forms)
  10. Reason for absence 9 of 23 (9 of 23 forms)
  11. Department, section or ward 8 of 23 (8 of 23 forms)
  12. Can do the essential functions? 7 of 23 (7 of 23 forms)
The 23 forms we read
  1. Winston-Salem State University · university, US
  2. Oregon Department of Administrative Services, Risk Management · state agency, US
  3. City of Trenton, Ohio · city government, US
  4. University of California · university system, US
  5. Michigan Technological University · university, US
  6. Oregon Institute of Technology · university, US
  7. CSUSM Corporation (Cal State San Marcos auxiliary) · university auxiliary, US
  8. Cape Fear Community College · community college, US
  9. The University of Kansas Health System · hospital system (employee health), US
  10. Maryland Department of Budget and Management · state agency, US
  11. Alfred University · university, US
  12. City and County of San Francisco, Department of Human Resources · city and county government, US
  13. University of North Carolina at Charlotte · university, US
  14. Baylor University · university, US
  15. York College, The City University of New York · college, US
  16. NHS North Yorkshire Clinical Commissioning Group · NHS body, UK
  17. Dover District Council · local council, UK
  18. University of Reading · university, UK
  19. North Lanarkshire Council · local council, UK
  20. The Shrewsbury and Telford Hospital NHS Trust · NHS trust (hospital), UK
  21. Trinity College Dublin · university, Ireland
  22. Cardiff and Vale University Health Board · NHS health board, UK
  23. Ebor Academy Trust · multi-academy trust (schools), UK

How the form changes as people answer

Most people see a shorter form. These questions and screens only appear when an answer calls for them.

  1. When “Type of leave” is Injury at work

    shows “Workers’ compensation claim number”

  2. When “How will your provider give the release?” is I will upload my provider’s own signed release

    shows “Your provider’s signed release”

  3. When “How will your provider give the release?” is My provider fills in the next section

    shows “Health care provider’s release”

  4. When “Work status” is not Not yet released

    shows “Can the employee perform the essential functions of their job?”

  5. When “Work status” is Released with restrictions

    shows “Restrictions”, “The restrictions are”

  6. When “Work status” is Released with restrictions and “The restrictions are” is Temporary

    shows “Restrictions apply until”

  7. When “Work status” is Not yet released

    shows the “Not cleared to return yet” ending

  8. At the end

    shows one of 2 thank-you screens: “Thanks, …”, “Not cleared to return yet”

Make it yours

  1. Send it to HR, not the manager

    In the Connect tab, turn on email and put HR’s address in Also send to.

  2. Let the employee finish at the appointment

    Save respondents’ progress on their device is on under Settings → Responses, so the provider’s part can wait for the visit.

  3. Say what happens if they are not cleared

    Edit the “Not cleared to return yet” thank-you screen to name your HR contact.

Good practice and the law

This is general information, not legal advice. Rules differ by country and state, so check anything important where you operate.

  • US

    Return-to-work questions must be limited to what is needed to judge the employee’s ability to work, and the answers kept as a confidential medical record. EEOC, disability-related inquiries

  • UK

    Up to seven days off needs no fit note; after seven days in a row the employee must give one. GOV.UK, taking sick leave

  • UK

    A return-to-work meeting is not required by law, and the employee need not tell you anything. Acas recommends one. Acas, returning to work

Questions about this template

Why does the release not ask for a diagnosis?

HR needs to know whether someone can do the job, and with what limits, not why. PulseFormCreator is not HIPAA compliant, so the release stops at work status and restrictions.

Can the provider use their own release form?

Yes. The employee uploads it instead, as long as it shows the return date, any restrictions and a signature.

How does the provider fill in their part?

The employee opens the link at the appointment and hands over the phone, or prints the PDF and uploads the signed page.

Is there a version for a UK return-to-work meeting?

Pick “Return-to-work interview” above the preview. No UK or Irish form we read has a provider section: the manager records the meeting, the fit note, support, agreed actions and trigger points.

Which form do you need?

The return to work form is one of the hr & employee forms. If it is not quite the job, one of these may be.

Start with the return to work form template

Open it in the editor, name HR in the note at the top, and send the link before the appointment.

Use this template

Updated 22 September 2026. Evidence read September 2026 from 23 real forms.