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Getting Started - RTW Forms & Templates

To begin, your company should designate a Return-to-Work (RTW) program coordinator to work with employees, doctors and NYSIF in all RTW cases. Once you identify a potential RTW case, alert NYSIF by forwarding the "Notice to NYSIF" described below. When necessary, seek assistance from NYSIF Claims and Policyholder Services managers who are available to assist your program coordinator.

Below is an explanation of the forms to use in your Return-to-Work program. Form titles link to Return-to-Work templates you can customize for your company. Download the RTW Flowchart for a step-by-step guide to the Return-to-Work process.

NYSIF offers instructions on saving templates for future use.

Title	Description/Instructions
Return-to-Work Policy Statement	Serves notice and explains your RTW policy to employees. We recommend presenting this to new employees upon orientation and redistributing this on a regular basis to all employees. Employees should know what to expect if they are injured on the job, and that their healthy recovery is a top priority that involves them, their doctors and their supervisors.
Notice to NYSIF of a Return-To-Work Case	Alerts NYSIF that you have identified an injured employee as a possible participant in your RTW program. In some cases, NYSIF will notify your company to a claim potentially appropriate for RTW.
Return-to-Work Job Demands Analysis	This is filled in by the employer and accompanies the Doctor Notification Letter. It summarizes the employee's current job duties and physical requirements of that job. You can also use this form to identify transitional duty throughout your company and present the doctor with a transitional position for your employee. Copy NYSIF.
Return-to-Work Doctor Notification Letter	Advises the doctor of your company's RTW program, directs the physician's attention to information about the employee's job demands, and asks the doctor to fill in, sign and return information concerning the employee's physical capabilities. This should be provided to the injured worker to give to the physician or sent to the physician directly by you. Copy NYSIF after the doctor completes the form.
Return-to-Work Availability Letter	This should be sent to the injured worker by certified mail as a documented offer of a transitional duty position; a copy should be kept on file by the employer, and a third copy sent to NYSIF. This letter is an important document if transitional duty is refused.
Return-to-Work Physical Capabilities Worksheet	This form accompanies the Doctor Notification Letter to be completed by the doctor upon examination of the injured worker. It should be provided to your employee to start the RTW process once an injury is reported. You should also send it to the treating physician on a regular basis, so that work restrictions can be addressed at each examination. Copy NYSIF after the doctor completes the form.

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Getting Started - RTW Forms & Templates

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