Worksheet

Work Restriction Tracker

Use this worksheet to compare doctor restrictions with actual job duties. It is a planning aid, not a legal filing.

Fields to fill in for Work Restriction Tracker

  • Injury date, report date, and first medical visit for the work restriction tracker.
  • Employer, job title, supervisor, and claim administrator connected to compare doctor restrictions with actual job duties.
  • Body parts or conditions accepted, denied, or disputed in the work restriction tracker.
  • Current restrictions, missed work dates, and payment gaps that affect compare doctor restrictions with actual job duties.
  • Notes needed to compare doctor restrictions with actual job duties.

How to use the work restriction tracker

StepWhy
Write work restriction tracker dates firstWorkers comp disputes around compare doctor restrictions with actual job duties often turn on timing.
Attach the work restriction tracker sourceA document is stronger than memory when trying to compare doctor restrictions with actual job duties.
Separate work restriction tracker facts from opinionsAttorneys can evaluate compare doctor restrictions with actual job duties faster with clean timelines.
Update the work restriction tracker after each noticePayment stops, denials, and restrictions can change how to compare doctor restrictions with actual job duties.

Privacy note for Work Restriction Tracker

Do not post private medical or employment details from the work restriction tracker publicly. Share sensitive records only with a licensed attorney, official agency, or trusted claim professional.

Before using the work restriction tracker for a consultation

  • Circle every missing work restriction tracker document rather than guessing.
  • Mark facts you know directly and facts someone else told you about compare doctor restrictions with actual job duties.
  • Keep a clean copy of the work restriction tracker for yourself.
  • Do not let the work restriction tracker replace official forms or attorney advice.