1
100‐CCO‐06‐IGDO
RETURN TO WORK – WEEKLY PROGRESS REPORT
RETURN TO WORK – Weekly Progress Report Date:
Employee Name:
Employee Number: Employee Department: Part of Body Injured:
Weekly Progress Report
Instructions:
1. This form should be filled out starting on the first day the employee is back to work and on the first shift at the start of each week,
until the completion of the Return to Work Procedure and the injured employee has returned to regular pre‐injury duties.
2.
The progress report should be signed by the injured employee, the supervisor and the manager/owner.
Date
Review of Progress
Please comment about your physical condition, what work tasks are you
able to perform easily and what work tasks are troublesome for you
Employee Supervisor Manager
Tasks that I am able to complete:
Tasks that are still very challenging to complete:
Progress made since the last report:
Actions required for the next shift in order to progress:
Concerns regarding the work or RTW Program:
PRINT
NAME:
PRINT
NAME:
PRINT
NAME:
SIGNATURE: SIGNATURE: SIGNATURE:
