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Name: _______________________________ Campus Box #: ____________ Supervisor Name: _____________________________________________________ *I have taken into consideration the job description and this patient may return to: _____Regular Duty as of (Date): ___________________________________________ _____Modified Duty as of (Date): _________________ Until Date:________________ with the following restrictions: _____No Repetitive Gripping _____Awkward Position _____No Repetitive Bending/Twisting _____Limited Outside Work _____No Repetitive Lifting _____Limited Exposure Extreme Heat/Cold _____No Pushing/Pulling/Reaching _____No Dust/Mold/Fumes/Smoke/Gases _____No Lifting Above Shoulder Level _____No Exposure Chemicals _____No Lifting Above Waist Level _____Limited Walking/Running/Jumping _____No Squatting/Crawling/Kneeling _____No Repetitive Turning _____No Driving Motor Vehicles _____No Repetitive Stooping _____No Climbing _____Limited Sitting/Standing _____Weight Limit __________lbs. _____Limited Balancing/Carrying/Holding _____Other, please specify: ______________________________________________________ ______________________________________________________________________________ Physician Comments:___________________________________________________________ ______________________________________________________________________________ ________________________________________ ______________________________ Examining Physician Name (Please Print) Type of Practice/Medical Specialty ________________________________________ __________________________ Examining Physician Signature Date ________________________________________ __________________________ Examining Physician Address Phone Number _________________________________________ __________________________ Employee Signature Date Return to Human Resources, fax: 316-978-3201     Revised 05/2014 $%4Fs}~  7 F e  , - H b ѾܨܤܨܠܒwohOJQJhlOJQJhOJQJhh';OJQJhhIK=h';5>*hH1h)hHh)h';5>*h3Ph';5 h3P5 h3P5\ hSQ*5\ h';5\h+A5h'; hVCJ0 h|CJ0 h';CJ0jh|UmHnHu+456}~  i j  , - d 2 u = q dgd>=$a$gdV  1 B G W a j t  ) 4 < N p ; I a s t !(xh,dOJQJh,dh';OJQJh';h)OJQJh)h)5OJQJh3POJQJh3Ph';OJQJh[;h';OJQJh[;OJQJhlOJQJh&,OJQJh#_h';5OJQJhfGOJQJhh';OJQJhOJQJ,  a IHtu   # $da$gd|dgd|dgd>=(HISp %stu   "#$%& h,dCJh0JCJhh=0JCJh,d0JCJh,dhw jhw Uh|h';OJQJ hTu{56 h56h|OJQJh,dh,dOJQJh,dOJQJh,dh}sOJQJh,dh';OJQJhHOJQJ*#$%& $da$gd|21h:p g/ =!"#$% F--  rIDmzmJFIF``ExifII*CC5" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?( 7mX EFeQ?~26r t-y2{ 8 y89xp 8<2,-jForU%MWmRQڋ6p5pJudv>Aa_#û.k{bmĞ* qZ\'1emoZ?h_^"5m.W_/ѭk_oTGI=kE>.xmOğ f߆w 6eƅ{4Ptmíge|l{yif|\-kC kx7~"ҵ/_gO fxd}}1jn\ܛmd[Zj֟cї׍c'3u|7Us)opyxtjWMC)fʌ,JO7J*9ʊj5S?}Ў. ?g ݯk=$?_%iUx?U(9hj>*'Ͱ <'6{Z] 8wdPhS -τT*I_Zl׼kZMu oNu{}BRX4;>𾱳ܰ<?}C¾8օ j\׺m_IL=:iymm/{ikt?ht\k_ 5ht}#O :V~!KUO'(EԌa>˞0ڌf7ưٻnڳj]ɫ7[޲=)ul/Ľ°QKNbӮ|ʦ=:_x+ǚ[Sg  퀴aжr_ܿ=?(}7 7, K⟉?4r&O:.5#GRXumk{jJ@"#i6|G[ jGυޛgm!iIe-6Z4 {=;tWπঞ+Ev UƱIԼq~'uCKӵͳ^7h.tD<6 ᇉ$|/G mi è<7Jvž4yŠ9ϳCI?1_(~>~s&<`a$o:.X>;~-[\I ese/{|R}^xSe>-kr?ᗆ>&[M4Sxֺ:m سb@Ys?]KN=Zo>?t~ӿ,Z~1~>՟ &][?,|-|HͬB 3fhoşMmHL?i/اžCo]~?}<|-mS;^rifH֣/YjZUݥ&z_{ ǟϋcs~/h|[>{Ǫ=k𷆼۳/ԭeKM%!Uq ^FolmnVem\*<ss[c:|/?ڗ~"_<14sKk(u-$vO~yy [?lr3_~_'5<.X'|50igMVO[+ms}X:}}Wrqq$Q#qK/ߵ9|8gڲ->i\=JMNĚnoNi`6זKxe!θs&W.̳5{-s`rLgVOΫyfqG.˲ڏUFa&_.pWB*q5+b*SR:V'R8uZP(J5j(R?v~,F{|P_Ow'I.oNlx>~ͬIfٷ-_^Ѭ/__[g^~ ~UO+u~ѿG٧nnf//>7 c o{{7|19~t~ɿ' 6Wzt}2m;zƏ[hVَ>dT +~ں;_~ x'fL{}-v^H^hE躴e+_k-2=%F\1QN$OeObyUf9>?x ™}<ƾcMev?p?f^ڥopjᰴܥ^ Yny>xZPR^8¶.NֱGVy /Ÿ|yb_%g֗𮇮|F^ہ(Ax[GRgmo.m,gv~?g+v?>< kzKǡBE7Y:γi^^m?T?_R_% o;8/vε<=i:mx<5aŮ667KZjlGyk/~N ~ A[r_ |SuE^[!^ \x{OmcHcxhG>ଷ~&0ypd>'-8ÅY uOaqv?r~)x寈*<Xbr=ZZ[8u1倞e,$EajT"UB_tUcN?f߁^5o)NJ5\ ?j}#GO'Ҭgռ&Z*kiw'l^ q_"]෈4k{ߍ~'䵒U}m>Omk]ݵ՝{g}w>>୿A/7_N3^f|''~OxXѴ SLռIiis1xnLm>h tTU~?I(W5_ۃ^}37.^cz߈l<=wx=:dZ Vռ"tdhzwuwheʳʨfo3,8%z3"bG_G[Cù<ܣ ; hasxbU%,{J|~N4~*9ca,._!hSjjW[u"/^?ڗWt?'΋kx~}.AA k i'csyeawg .g+~.߷|/|?ٟ፞715,YhzE6[MTVࣿQ۟t/c㦵?Zh=o^&yiLQ[iz]s "[mUc_@ #)f9uI` 3"S)pԩ|l[e9(*eet|(Nf<_y|"ekO H;k ǣ>a RԲ-Ww>e[Y _NMk}.)4GMr|yyL nj<"Sg0W_߲-?Ms ֜ o .Bg?|$aåCs{};D4o'KK&W ·:7:77e+$+8?O-e%"?.4?/s9'o OMljŷ&2m?೺~!a_/(oÿ&X<~ORx. 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