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. For assistance, call (217) 383-8369.

RETURN TO WORK FORMS

Transitional Work Program – Individual Work Return Plan (IWRP) 
Outlines the individual’s job responsibilities in the recovery process

Transitional Work Abilities
Explains the physical requirements of a job to the physician

Transitional Employment Progress Report
Informs the physician about an injured employee’s progress

Request for Medical Care and/or Testing
Informs medical providers in emergency care facilities, useful for post-accident drug screens

Evaluation Forms

Carle Clinic/Carle Foundation Hospital OSHA Medical Respirator Evaluation Questionnaire
Form for Carle Clinic and Carle Hospital employee use only
 
OSHA Respirator Medical Evaluation Questionnaire
Form for employees of any company other than Carle Clinic and Carle Foundation Hospital