What this is
What is a work restriction record?
What is a work restriction record?
It is the record of what a specific worker can and cannot currently do, arising from an injury, illness or condition, stated as function rather than diagnosis. It names the restrictions, sets an effective period and review date, and records whether the supervisor and worker both understood and agreed to it.
How does a restriction record differ from a modified duty plan?
The restriction record states the limit; the modified duty plan states the job built around it. A restriction of no lifting over five kilograms is one line in this record and the starting constraint for a separate plan that decides which tasks the person will actually perform for the duration.
Who decides what a restriction says?
Whoever is named as its source. Occupational health advice and a treating clinician's note carry the most weight and score highest in this template; a self-declared or manager-observed restriction is weaker evidence and should be followed up with a clinical opinion rather than treated as equivalent.
Scope
When is a work restriction record required?
This is the statement of limits, not the plan built around them and not the case they belong to. Its most common misuse is being filled in as a general update on how the worker is doing, which produces a record too vague for a supervisor to apply and too thin for the case file it should be feeding.
Use this template when
- Occupational health, a treating clinician, or a documented self-declaration establishes a functional limit for a specific worker
- A new restriction is being issued; each one gets its own ID in the form WR-2026-000
- You are running the Return to Work programme and a restriction needs to be on file before duties can be assigned around it
- A linked record needs this one to exist: the modified duty plan, the authorisation matrix and the case record all depend on the restriction being stated first
- An existing restriction needs to be extended, tightened, loosened or confirmed at review
Do not use it for
- Modified Duty Plan, which sets out the specific temporary duties the worker will perform once the restriction is known
- Return to Work Interview, which records the return conversation on any absence, covering fitness and adjustments generally rather than a specific functional limit
- Return to Work Programme Plan, which sets the site-wide arrangement, triggers and roles that this individual restriction sits underneath
- Occupational Health Case Record, which is the case index this restriction should be linked to, not duplicated inside
- Suitable Duties Register, which lists what work is available on site, independent of any one worker's restriction
Compliance mapping
Which ADA requirements does this satisfy?
The obligations here split cleanly: what may be disclosed and to whom is a confidentiality duty, and what accommodation follows from the restriction is a separate accommodation duty, with workers' compensation regimes adding their own return-to-work expectations on top.
| Clause | Requirement | Where it lands |
|---|---|---|
| ADA 29 CFR 1630.14(c) | Medical information obtained through employment-related inquiry kept in separate confidential files | Header |
| ADA 42 USC 12112(d)(3)(B) | Supervisors may be told only the restrictions and necessary accommodations, not the underlying medical condition | Communication and effect |
| ADA 29 CFR 1630.2(o) | Reasonable accommodation determined through an interactive process addressing the individual's actual functional limitation | Restrictions |
| OSHA 29 CFR 1904.7(b)(4) | Days of restricted work or job transfer counted as a recordable outcome regardless of how the modified duty was arranged | Duration and review |
| WCB early and safe return to work guidance | Employer and worker duty to cooperate in identifying suitable modified work for the duration of a temporary limitation | Duration and review |
| ISO 45001 cl.7.4 | Internal communication of information needed by those who must act on it, in a form they can use | Communication and effect |
What it does not cover
- Modified Duty Plan, which sets out the specific duties, hours and equipment built around the restriction, once the restriction itself is stated.
- Occupational Health Case Record, which is the case index this restriction should be linked to by its case ID, not a substitute for one.
- Return to Work Interview, which covers the general return conversation, fitness and adjustments, rather than a single documented functional limit.
- Authorisation or competency record, which is where a training or authorisation status actually gets suspended once a restriction affects it, not this record alone.
- Clinical assessment itself, which sits with occupational health or the treating clinician and is only referenced here, never restated.
Global
Work Restriction Record requirements by country
The basis named for this template is US disability accommodation law and Canadian workers' compensation board guidance, and those two instruments carry most of the weight; where the template also travels is the general management-system expectation that a restriction, once issued, is communicated and acted on.
ADA 42 USC 12112(d)(3)(B) and 29 CFR 1630.14(c); OSHA 29 CFR 1904.7(b)(4)
Medical confidentiality is a statutory floor on disclosure, and restricted work is separately a recordable event on the injury log.
A restriction record that leaks diagnosis to a supervisor is a compliance failure on its own, independent of whether the restriction itself was reasonable.
Provincial workers' compensation legislation and early and safe return to work guidance, for example WSIB Ontario
Employer and worker are both under a duty to cooperate in identifying suitable modified work for the period a restriction applies.
Failure to accommodate a documented restriction can affect the employer's claim costs directly, not only its legal exposure, which is why the extension and review fields carry real weight in Canadian practice.
ISO 45001 cl.7.4
Information needed to act safely has to reach the people who need it, in a form they can use, which for a supervisor means function and duration rather than clinical detail.
A certification audit looking at this record checks that it was communicated and understood, not only that it was signed by occupational health.
How to complete it
How to complete a work restriction record, step by step
The form captures the restriction cleanly. What determines whether it holds up is whether it was checked, whether it reached the authorisation matrix, and whether an extension was treated as routine or as a warning sign.
Lifting limit, repetitive task limit and the named restrictions on height, driving, confined space, cold store and respirator use are all functional statements a supervisor can apply directly. Resist adding why in the other restrictions field; if a reason is genuinely needed for planning it belongs in the case record with occupational health, not in the field the supervisor will read.
Restrictions being followed exists precisely because issuing a restriction and checking it are two different acts. Set the compliance check date when the restriction is issued, and treat a Partly or No answer as the case management event it is, not as a note to revisit later.
A restriction that removes no driving or mobile equipment, or no confined space entry, has a direct consequence for the person's authorisation status. Recording authorisations affected as Yes without an authorisation ID and without confirming the matrix was updated leaves the person formally licensed for work they are currently restricted from doing.
Restriction extended more than once, alongside expected duration drifting toward indefinite, is the pattern that should raise a modified duty plan review or a fresh clinical opinion, rather than a third routine renewal of the same restriction with the same review date pushed further out.
What auditors find
Most common work restriction record findings
The restriction itself is usually recorded accurately. The findings concern what happens to it after it is issued, and whether the record shows anyone checked.
| Finding | Clause | What fixes it |
|---|---|---|
| Restrictions being followed left unanswered or marked Yes with no compliance check date recorded. | ISO 45001 cl.7.4 | Require a compliance check date at issue and an evidenced answer before the review date. |
| Diagnosis or clinical narrative entered in other restrictions or rest break adjustments, despite only functional limits shared being answered Yes. | ADA 42 USC 12112(d)(3)(B) | Restrict free-text fields to functional description; audit them against the confidentiality answer. |
| Authorisations affected answered Yes with no authorisation ID and matrix updated left as No. | ADA 29 CFR 1630.2(o) | Block sign-off until the authorisation ID is entered and the matrix update is confirmed. |
| Restriction extended more than once with no escalation to a modified duty plan or renewed clinical opinion. | WCB early and safe return to work guidance | Trigger a case review automatically on a second extension rather than allowing indefinite renewal. |
| Review date passed with the restriction still marked temporary and no renewal or closure recorded. | OSHA 29 CFR 1904.7(b)(4) | Flag restrictions past their review date as overdue rather than leaving them silently in force. |
| Source of restriction recorded as self declared or manager observation with no follow-up clinical confirmation. | ADA 29 CFR 1630.2(o) | Require occupational health or treating clinician confirmation within a stated period of a self-declared restriction. |
Case in point
Case in point: the restriction the matrix never saw
A warehouse issued a work restriction for a picker recovering from a shoulder injury, correctly recording no driving or mobile equipment and no working at height, sourced from occupational health advice, with the supervisor informed and only functional limits shared. The restriction was signed by the case manager and the supervisor, and the record was filed as complete.
Three weeks later, during a shift change, a different supervisor short of forklift-certified staff pulled the same worker onto reach truck cover for the afternoon, using the authorisation still showing active in the training matrix. Nobody had updated authorisations affected or entered an authorisation ID against the restriction, so the matrix carried no signal that the certification should have been suspended. The worker drove for four hours before the original supervisor noticed and stood him down. No injury resulted, but the near miss investigation found the restriction record, the training matrix, and the rota had never been connected to each other, and the field designed to connect them had simply been left blank.
The template
The template, field by field
The form exactly as it installs. Every field, option, score and conditional rule is editable, and the links to other templates come with it.
4 sections
- Reference
- HLT-017
- Archetype
- Record
- Record ID
- WR-2026-000
- Scoring
- Not scored
- Direction
- n/a
- Singleton
- No
- Basis
- ADA, WCB guidance
- Links
- Links Worker, Job
- Tags
- Health, Case
- Sections
- 4
- Fields
- 42
- Follow up fields
- 1
- Repeating sections
- 0
- Links out
- 4
Header
12 fieldsRecord ID*
Auto sequence. Format RES-2026-000.
The record's own ID. Other templates point at this value.
Status*
Drives who this goes to next.
- Planned2 pts
- In progress2 pts
- Complete3 pts
- Deferred0 pts
- Open0 pts
- Closed3 pts
- Overdue0 pts
Date and Time*
Completed By*
Site*
Site ID*
Format SITE-000.
Links to FDN-001 Site ID
Worker*
Person ID*
Format PER-0000.
Links to FDN-003 Person ID
Function, Not Diagnosis
This record states what the person can and cannot do. It contains no medical information, because the supervisor applying it does not need any and should not have it.
Case ID
Thread key
Source Of Restriction*
- Occupational health advice3 pts
- Treating clinician3 pts
- Self declared1 pt
- Manager observation1 pt
Referral ID
Links to HLT-013 Referral ID
Restrictions
12 fieldsLifting Limit
Repetitive Task Limit
Standing Or Walking Limit
No Working At Height
No Driving Or Mobile Equipment
No Confined Space Entry
No Cold Store Work
No Respirator Use
No Night Shift
Other Restrictions
Rest Break Adjustments
Equipment Or Aid Required
Duration and review
6 fieldsEffective From*
Review Date*
Expected Duration*
- Under 2 weeks3 pts
- 2 to 6 weeks2 pts
- 6 weeks to 3 months1 pt
- Over 3 months0 pts
- Indefinite0 pts
Permanent Or Temporary*
- Temporary with review date3 pts
- Permanent1 pt
Restriction Extended
- No3 pts
- Once1 pt
- More than once0 pts
Times Extended
Communication and effect
12 fieldsSupervisor Informed*
- Yes3 pts
- No0 pts
Only Functional Limits Shared*
- Yes3 pts
- Medical detail shared0 pts
Worker Agrees Restrictions Are Understood*
- Yes3 pts
- Partly1 pt
- No0 pts
Authorisations Affected*
- No3 pts
- Yes1 pt
Authorisation ID
Links to TRN-024 Authorisation ID
Matrix Updated*
- Yes3 pts
- No0 pts
Restrictions Being Followed
Checked in practice. Restrictions that exist only on paper are common and dangerous.
- Yes3 pts
- Partly1 pt
- No0 pts
Compliance Check Date
Case Manager*
Signature*
Supervisor*
Second Signature*
HLT-017 · record IDs look like WR-2026-000 · Links Worker, Job
Open in KnowellaRun it with agents
From a document you fill in to a programme that runs itself
The restriction itself is usually written correctly. What fails is everything downstream of it: the matrix that was never updated, the rota that was built without checking it, and the review date that passed unnoticed.
Holds the restriction against the case it belongs to, flags overdue reviews, and links it forward to the modified duty plan it should be feeding.
Watches shift assignments against active restrictions and raises a conflict before a restricted worker is rostered onto a task the restriction rules out.
Cross-checks authorisations affected against the current training and competency matrix, so a suspended authorisation does not sit active by omission.
Feeds a pattern of restrictions on the same task or area back into the relevant risk assessment, so recurring restrictions become a control question rather than individual accommodations.
This template lives in KnowHealth — employee wellbeing. Exposure monitoring, health surveillance, case management and return to work.
Meet KnowHealth→Glossary
Work Restriction Record definitions and key terms
- Functional limitation
- What a worker can and cannot currently do, stated in terms of capability rather than diagnosis, prognosis or treatment.
- Source of restriction
- The origin of the restriction, ranked by evidentiary weight from occupational health advice or a treating clinician down to a self-declared or manager-observed limit.
- Authorisation matrix
- The record of who currently holds a licence, permit or competency to perform a controlled task, which a restriction affecting that task needs to update, not just note.
- Compliance check
- A verification, after the restriction is issued, that it is actually being observed in the work assigned, as distinct from having been recorded and communicated.
- Permanent restriction
- A restriction with no expected end date, which shifts the case from a temporary accommodation to a standing one that a modified duty plan needs to be built around indefinitely.
FAQ
Frequently asked questions about work restriction record
Can a restriction record include the diagnosis for context?+
No. The form exists specifically so that it does not need to. If the restriction itself, stated as a functional limit, does not give the supervisor enough to act on, the record is incomplete on its own terms; adding diagnosis does not fix that, it just adds information the supervisor has no right to and the record was never meant to hold.
What counts as checking that a restriction is being followed?+
Confirming the actual tasks assigned in the period since issue against the stated restrictions, not asking the worker whether everything is fine. A short conversation with the supervisor, checked against the rota, is usually enough; a compliance check date with no evidence of what was checked is not.
Should a self-declared restriction be accepted as-is?+
Provisionally, yes, because refusing to act on a worker's own statement of what they can do is its own risk. It should not be treated as equivalent to an occupational health or clinician source, and a follow-up to obtain clinical confirmation should be scheduled rather than skipped because the self-declared restriction is already on file.
What should happen when authorisations affected is Yes?+
The authorisation or competency matrix has to be updated in step with this record, not afterward. An authorisation ID entered here without confirmation the matrix reflects it is a gap the person can drive, climb or enter through before anyone notices.
How many times can a restriction reasonably be extended?+
Once, without much comment. A second extension should trigger a case review rather than a routine renewal, because a restriction still needed after two review cycles is usually describing a case that has not been reassessed properly, not a slow but steady recovery.
Who signs the restriction record?+
The case manager and the supervisor, both. The case manager's signature confirms the restriction was correctly issued; the supervisor's confirms it was received and understood, which is the point at which the record's effect actually starts.
Keep going
Related templates and programmes
Industries this is written for
Programmes this belongs to
Used together in Return to Work
Occupational Health Case Record
Records and tracks a health case from first report through to closure
Modified Duty Plan
Sets out the temporary duties a recovering worker will perform
Case Progress Review
Reviews how a health case is progressing against its expected timeline
Case Closure Record
Closes a health case, recording the outcome and any lasting restrictions
Claim Support Record
Records the information provided to support a workers compensation claim
Absence Trend Review
Reviews absence patterns by area, shift and cause category to find where work is making people ill
More in Return to Work
Modified Duty Plan
Sets out the temporary duties a recovering worker will perform
Return to Work Interview
Records the conversation on return from any absence, covering fitness, adjustments and whether work contributed
Return to Work Programme Plan
Sets out how the site brings people back to work after injury or illness, covering triggers, roles, timescales and the duties that are actually available
Stay at Work Record
Keeps somebody at work on adjusted duties instead of signing them off
Return to Work Referral
Opens a return to work case and gathers what is known so far about the absence, the person and their job
Return to Work Meeting Record
Records the meeting between the worker, their manager and occupational health where the return is agreed
Written and reviewed by
Siddarth Singh
Founder & Chief Executive Officer, Knowella
Certified Safety Professional and industrial and systems engineer with more than a decade inside food supply chain, freight and manufacturing operations. This page was written against the current text of the standards it cites, not against secondary summaries of them.
- Certified Safety Professional (CSP), Board of Certified Safety Professionals
- MBA, University of Chicago Booth School of Business
- MS and BS, The Ohio State University, Industrial and Systems Engineering
- Six Sigma Black Belt
Sources and last review. Reviewed 16 August 2026 against:
- ADA regulations 29 CFR 1630.14(c) and 1630.2(o); 42 USC 12112(d)(3)(B)
- OSHA 29 CFR 1904.7(b)(4), recording days of restricted work or job transfer
- WSIB Ontario early and safe return to work guidance (representative of provincial WCB practice)
- ISO 45001:2018 clause 7.4
This page is general guidance, not legal advice. Confirm requirements with your jurisdiction’s regulator.