Utah > Workers Compensation
Release To Return To Work 110 - Utah
| Release To Return To Work Form. This is a Utah form and can be used in Workers Compensation . |
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Print Form Form 110 RELEASE TO RETURN TO WORK PLEASE PRINT OR TYPE Instructions: This form must be submitted when an injured worker's temporary disability compensation is less than 90 days. The form must be completed by the Adjustor after receiving a Physician's notification of release to return to full or light duty. The form must be submitted to the Reemployment Office within five (5) working days of the release date. General Information Worker Name __________________________________ Address ______________________________________ Phone Number ______________________ Social Security Number ___________________ Injury Date ____________________________ Employer _____________________________ Actual Number of Lost Work Days ____________________________ Released to Regular Duty Released to Light Duty Date _____________________________ Permanent Impairments, if any: _________________________________ _________________________________ Date ______________________________ Permanent Impairments, if any: __________________________________ __________________________________ Anticipated Date of Release to Regular Duty: _____________________________________ Name of Person Submitting Form ______________________________________________________ Carrier Name ______________________________________________________________________ Phone Number _____________________________ Date Submitted _________________________ Official Form 110 Revised 2/09 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com
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