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ATTACHMENT G

PMD Cracker Project


RETURN TO WORK NOTICE

NAME

ADDRESS

DATE ABLE TO RETURN TO REGULAR WORK DATE ABLE TO RETURN TO MODIFIED WORK

RESTRICUTIONS/LIMITATIONS

UNABLE TO RETURN TO WORK UNTIL (DATE) DATE RETURN TO DOCTORS

MEDICATION PRESCRIBED?
PRECAUTIONS
 YES  NO

DIAGNOSIS

DOCTOR’S SIGNATURE

DOCTOR’S ADDRESS

DATE TIME

PROJECT NAME/NO.

PROJECT ADDRESS

INSURER

579615208.doc

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