This template is for employers to get information from a health care provider (physician, nurse practitioner, physiotherapist, etc.) about an injured employee’s functional abilities after a work-related injury. This information can be used to plan a safe and timely return to work for the employee.

To use this template:

1. Download the template and fill in the blank fields in the letter to the health care provider on page 1.
2. Give the letter and blank assessment to your employee who has experienced an injury at work.
3. Ask the employee to take both to their health care provider and return the completed assessment to you.
4. Use the information in the assessment to help identify suitable work for them.

To learn more about helping an injured employee return to work, visit worksafebc.com/returntowork.