Get the free Modified Duty Assignment Form - BCN - unr

BUSINESS CENTER NORTH (BCN) WORKERS COMPENSATION OFFICE TEMPORARY MODIFIED-DUTY ASSIGNMENT ACKNOWLEDGMENT EMPLOYEE NAME: DATE OF INJURY: DESCRIPTION OF TEMPORARY MODIFIED-DUTY POSITION: PHYSICAL RESTRICTIONS:

How to fill out modified duty assignment form

How to fill out a modified duty assignment form:

1. Fill out the employee's personal information, including their name, job title, and contact information.
2. Provide details about the injury or illness that prevents the employee from performing their regular job duties.
3. Describe the specific modified duties or responsibilities that the employee will undertake during their recovery period.
4. Indicate the anticipated start date and duration of the modified duty assignment.
5. If applicable, attach any supporting medical documentation or notes from healthcare professionals.
6. Obtain the employee's signature and date on the form to acknowledge their agreement to the modified duty assignment.

Who needs a modified duty assignment form:

1. Employees who have sustained a work-related injury or illness that temporarily prevents them from performing their regular job duties.
2. Employers who are committed to providing appropriate accommodations to injured or ill employees, enabling them to continue working in a modified capacity while they recover.
3. Human resources or occupational health professionals responsible for coordinating the implementation of modified duty assignments and tracking employee progress.

For pdfFiller’s FAQs

What is modified duty assignment form?

The modified duty assignment form is a document used to notify an employer about an employee's temporary work restrictions due to a medical condition or workplace injury.

Who is required to file modified duty assignment form?

An employee who has temporary work restrictions due to a medical condition or workplace injury is required to file the modified duty assignment form.

How to fill out modified duty assignment form?

To fill out the modified duty assignment form, the employee must provide their personal information, details of the medical condition or workplace injury, the restrictions imposed, and the expected duration of the restrictions.

What is the purpose of modified duty assignment form?

The purpose of the modified duty assignment form is to inform the employer about an employee's temporary work restrictions and facilitate the process of providing appropriate accommodations or modified duties.

What information must be reported on modified duty assignment form?

The modified duty assignment form should include the employee's personal information, details of the medical condition or workplace injury, the restrictions imposed, and the expected duration of the restrictions.

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