Did you know?
According to the American Journal of Preventive Medicine, employers who invest in worksite health promotion programs can see a return of $3-$6 for every dollar invested over a two to five year period.

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Urbana
 PH (217) 383-3077

Danville on Vermilion

 PH (217) 431-7606

Rantoul

 PH (217) 893-7710

 

 

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

  • Outlines the individual’s job responsibilities in the recovery process

Transitional Work Program - Individual Work Return Plan (IWRP)

Transitional Work Program - Individual Work Return Plan (IWRP) 

  • Explains the physical requirements of a job to the physician

Transitional Work Abilities

Transitional Work Abilities

  • Informs the physician about an injured employee’s progress

Transitional Employment Progress Report

Transitional Employement Progress Report

  • Informs medical providers in emergency care facilities, useful for post-accident drug screens

Request for Medical Care and/or Testing

Request for Medical Care and/or Testing

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

 
Copyright© 2008 Carle Physician Group