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Duration
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|
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Return to school WITHOUT restrictions
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Return to work WITHOUT restrictions
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Return to work/school with the following restrictions
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|
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Restrictions
• • •
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Limit working hours (daily)
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Position changes whenever necessary
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No lifting, pushing, or pulling in excess of _ pounds
|
|
No overhead reaching or lifting with:
• • •
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Other
|
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Return Visit Date
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Provider Signature
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South Austin Location
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Round Rock
|
