Employer Forms

Below is a list of forms commonly used by employers and employees that are members of our programs and services. Click on the name to download a form, available in pdf or Word.

RETURN TO WORK FORMS

This form outlines the individual’s job responsibilities in the recovery process:

• Transitional Work Program - Individual Work Return Plan (IWRP) PDF
• Transitional Work Program - Individual Work Return Plan (IWRP) Word

This form explains the physical requirements of a job to the physician:

• Transitional Work Abilities PDF
• Transitional Work Abilities Word

This form informs the physician about an injured employee’s progress:

• Transitional Employment Progress Report PDF
• Transitional Employment Progress Report Word

This form provides useful information post-accident drug screens:

• Request for Medical Care and/or Testing PDF
• Request for Medical Care and/or Testing Word

EVALUATION FORMS

• Carle OSHA Medical Respirator Evaluation Questionnaire (for Carle and McKinley employees)
• OSHA Respirator Medical Evaluation Questionnaire (form for employees of any company other than Carle)
• Patient/Family Medical History
• Audiology Questionnaire
• OSHA Cadmium Exposure Health History Questionnaire

For more information, contact Tom Cottrell, Employee Relations Coordinator, at (217) 383-6730 or tom.cottrell@carle.com.