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Get Weber State University Employee's Return To Work Form

Date of Onset: Date(s) of Treatment: History: Name(s) of other physician(s) or medical providers who have served on case: Diagnosis: Treatment (Proposed or completed): Medication(s): Prognosis: Estimated return to work date: First day off work: Actual Return to Work without restrictions: Return to work with reduced schedule: Number of hours per day: Number of days per week: Beginning: Ending: Return to work with the following restriction.

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