Work Restriction Letter From Doctor Sample (with Guide)


Work Restriction Letter From Doctor Sample (Guide)

This is a doctor's letter to management requesting that an employee's working hours be limited. The person may be suffering from a sickness that makes working long hours difficult for them.

This letter is crucial because a manager needs to understand why an employee is requesting a work-hour limitation. With the help of a doctor's note, the employee's claim may gain credibility. We don't have any influence over an illness.

If at all feasible, we must continue to work, even if our hours are reduced. If an employee does not go to work, they may be unable to support their families. As a result, when an employee has a problem, this letter may be useful.

How to write a work restriction letter?

This letter will assist both the firm and the employee in understanding the employee's function after they return, as well as whether or not their typical tasks will need to be staggered when they return to work.
  1. A statement explaining why the employee will be unable to complete their job tasks, as well as that their boss and any higher-ups have approved this arrangement. Include the exact cause for the employee's absence (for legal documentation purposes) as well as the fact that the employee understands their job responsibilities will change when they return;
  2. You should also specify if the employee's role will change (for example, from full-time to part-time), as well as whether the change will be permanent or temporary.
  3. If the employee's benefits or salary may change as a result of their absence, you must tell them before they depart.
  4. Microsoft Word may be used to compose this letter.
  5. It is necessary to state the patient's name.
  6. The doctor can say when they last saw the patient and when they diagnosed the sickness or damage.
  7. The patient's sickness or injury might be indicated so that the employer is aware of the basis for the request for a work schedule limitation.
  8. It must be indicated when the employee's working hours should be restricted.
  9. The doctor should provide an estimate of how long these limits should be in effect.
  10. The patient's next appointment can be specified.
  11. In case the manager has to contact the doctor, the doctor's contact information, including name, address, phone number, and email address, should be provided.
  12. It is necessary to have the doctor's signature and date.

1. Work restriction letter sample

On (patient's name), I performed a physical examination (Date).

When did you get hurt or sick? (Date)

The patient mentioned above is medically fit to work, but only for a limited time (Date). The patient that was previously mentioned has (state the illness).


These limitations should be in effect until at least the end of the year (weeks of restriction).

Next appointment time and date (Date).

These limitations are based on the following factors:

The patient provided information, and I conducted an examination and a patient evaluation (tick which one).

This paperwork was presented to the patient listed above.

(Signature of the physician).

Employee Acknowledgement Form and Work Restrictions Response Letter

1. Employee Acknowledgement Form Sample

I, Ramesh, am aware that my treating physician has permitted me to return to work as of September 25th, subject to the following conditions:

[Make a list of constraints]

I realise that I am not authorised to undertake employment activities that require me to break the limits specified above under any circumstances. Should such work responsibilities arise, I shall ask or delegate them to another team member. 

I understand that my incapacity to do these motions at this time will not be considered when my performance is evaluated and that I will not face retaliation as a result of my present medical condition or work limitations. 

If I have any issues about this, I will bring them to the Human Resources Department's notice right away.

I am aware of the limits outlined above and promise to adhere to them at all times while working at ABV Company.

Employee Name:

Read:— Preservation Letter Sample 

NOTE:— Please keep in mind that this text is provided solely for educational purposes and does not represent legal advice.

2. Work Restrictions Response Letter

[Employee Name] 
[City, State ZIP Code] 

Dear [Employee Name], 

I'm writing to express my heartfelt gratitude for everything you've done for me.

To ensure that you follow your doctor's directions, we've changed your work tasks. We place a high value on your health and well-being. As a result, when you return to work, we urge that you proceed with caution and that you do not execute any job duties that require you to perform limited motions, as per your physician's note.

Your treating physician has mentioned the following work limitations in the letter that was sent to us on [Date] from your treating physician:


When you return to work, you mustn't try to do any of these things. You must delegate a work obligation that requires one of these banned activities to another employee. You must obey these limits while completing work for [Company Name] until you are further advanced in your rehabilitation and these restrictions are abolished.

Please rest assured that your handicap records will be kept confidentially in compliance with the ADA's rules.

We're pleased you've returned once more!


[Position Title and Name]

work restriction letter from doctor sample

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