Get Restriction Form.doc - Hopkinsmedicine

This guide provides comprehensive instructions on completing the Restriction Form required for employees with work-related restrictions. Filling out this form accurately is essential to ensure that necessary accommodations are made for the employee's health and well-being.

Follow the steps to complete the Restriction Form online.

1. Click the ‘Get Form’ button to obtain the Restriction Form and open it in your preferred editor.
2. Enter the employee’s name in the designated field. Ensure that you input the correct spelling for accuracy.
3. Fill in the employee's Social Security Number (SSN) in the corresponding space. This information is necessary for identification.
4. Indicate the diagnosis and provide the corresponding ICD-A or DSM III-R code number in the specified fields.
5. Select the affiliation from the checkboxes provided. Options include JHH, JHU, JHCP, JHHS, or OTHER.
6. Specify the return to duty date in the field provided. It is important for managing the timing of the restrictions.
7. Choose the duty status by checking either 'Full Duty' or 'With the following restrictions.' If restrictions are selected, detail them in the following section.
8. Indicate the maximum allowable percentage of a workday for the employee. Options include 100%, 75%, 50%, or 25%. Select based on the employee’s capability.
9. For each activity (standing, walking, sitting, bending, upper extremity), specify the percentage of workday or restrict as necessary. Circle the correct side (Right, Left, Both) as required.
10. For lifting, specify the pound limitations for each specified category, including horizontal, vertical, and overhead where applicable.
11. Provide any additional comments or other limitations that may be necessary for the employee’s situation.
12. Indicate the effective date for the restrictions and the duration they will remain in effect, measured in weeks.
13. Ensure the physician signs and prints their name in the designated areas, providing the phone number and date.
14. After completing the form, you can save changes, download a copy, print it for physical submission, or share it as needed.

Complete the Restriction Form online today to ensure timely processing and support for the employees' needs.