Forms are used to
communicate and document certain types of information. Listed below
are forms employers may print off and use for certain situations. A
description of each form included for your benefit.
Also listed below are important forms the Carle OCCM physician may
use to document certain types of information and send to you. Should
you have any questions regarding the forms or the information
contained in them, please call the Occupational Medicine department
at Carle.
Employer Forms
Transitional Work Program -
Individual Work Return Plan (IWRP)
Many companies have a return to work program (RTW) or temporary
transitional employment that accommodates an injured employee who
has restrictions. This is one sample of a form that you might use
to design an individual work return program. This sample form is
useful in planning graduated transitions with higher demands as
the person heals. Please involve your physician in your RTW
planning by sharing a copy of the developed plan.
Transitional Work Abilities
It is very important to provide the physician or surgeon with
needed information on the physical demands of the regular job or
the temporary job assignment. The form allows the employer to
explain the physical requirements of the job to the physician. The
physician can then give feedback to the company on any limitations
related to the job demands.
Transitional Employment Progress Report
It is helpful for physicians to have information regarding the
status and progress of the injured employee while participating in
the modified work or transitional employment program your company
offers. We invite you to use the Transitional Employment Progress
Report to streamline communication. This form invites all parties
to be involved in the information exchange to provide a safe early
return to work and provide information needed to make decisions at
the worksite.
Request for Medical Care
and/or Testing
This sample tool may be used to provide information to medical
providers in Emergency or Urgent Care facilities to inform them of
needed instructions or other information exchange. Please use this
as a guide and modify as needed for pertinent information such as
who the bill and report shall be sent. This form is particularly
useful for widespread workforces or those who are on the road and
need to have specific post accident drug screens done.
Work Ability Profile
This form is filled out by the Carle physician after a
pre-placement, annual/periodic or fit for duty exam occurs. The
information on the form details any limitations the employee
currently has in relation to work.
Illness Injury Report
This form is filled out by a Carle physician for each workers
compensation visit. The injured employee receives two copies of
the form at each visit. One copy is for the employee and the other
is for the company. The employee should submit the company
copy to the company representative after each visit. If a company
did not receive their copy from the employee, please contact an
occupational case coordinator and they will fax a copy.
Respiratory Clearance Form
This form is filled out by the occupational medicine physician
after a review of the employees respiratory health questionnaire
and/or physical examination. The form details the types of
respirators an employee is medically approved to use, activities
the employee may perform or the need for further medical
evaluation.
Carle
Clinic Association and Carle Foundation Hospital are separate business corporations that
work together to provide quality care and services to their patients.
Carle Clinic Association and Carle Foundation Hospital contract with insurance
providers separately and may or may not choose to participate in all of the same insurance
plans. Patients are urged to check with their insurance carriers as to whether services
are covered for either or both organizations.
