RELEASE TO RETURN TO DUTY PLEASE CHECK ONE. Patient may return to full duty with no restrictions on (date). Patient may only work a light duty assignment with the following medical restrictions to his/her performance of his/her job duties (Please be specific as to the medical restrictions and include a prognosis as to how long these medical restrictions will be in effect): Patient remains incapacitated and is unable to return to work at this time. (Please provide the estimated date of return to work in Section 1 above.)
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