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West Chester University Offices of Human Resources 201 Carter Drive Suite 100 West Chester, PA 19383 fax: 610-436-3464 Name of Employee Date of Injury Submit by Email MODIFIED WORK ASSIGNMENT FORM

How to fill out modified work form

How to fill out a modified work form:

1. Begin by obtaining a copy of the modified work form from your employer or human resources department. It may be available in a physical or digital format.
2. Read through the form carefully to familiarize yourself with the information required. This may include personal details, such as your name, employee ID, and contact information, as well as specifics about your work restrictions or limitations.
3. Fill in your personal information accurately and completely. Ensure that all fields or sections marked as required are completed.
4. Specify the nature of your work restrictions or limitations in detail. Provide any necessary medical documentation or recommendations from your healthcare provider to support your request for modified work.
5. If applicable, outline the accommodations or adjustments you are seeking in order to perform your job duties effectively within the prescribed limitations. This can include changes to your work schedule, tasks, or environment.
6. Review the completed form for any errors or missing information. Make any necessary corrections or additions before submitting it.
7. Sign and date the form, indicating your agreement with the information provided and your understanding of the process.

Who needs a modified work form:

1. Employees who have sustained a work-related injury or illness and are unable to perform their regular job duties.
2. Individuals with disabilities or medical conditions that require workplace accommodations in order to fulfill their job responsibilities.
3. Workers who have temporary or permanent physical or mental impairments that limit their ability to perform certain tasks and require modifications to their work environment or job duties.

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What is modified work form?

A modified work form is a document used by employers to outline changes to an employee's job duties or work schedule due to circumstances such as an injury or medical condition.

Who is required to file modified work form?

Employers are typically required to file a modified work form when an employee is unable to perform their regular duties due to medical reasons and is offered modified or alternative work options.

How to fill out modified work form?

To fill out a modified work form, an employer should provide the employee's details, describe the nature of the modified work, outline the duration of the modified duties, and indicate approval from a medical professional if necessary.

What is the purpose of modified work form?

The purpose of a modified work form is to document the temporary adjustments made to an employee's job role to facilitate their return to work while accommodating their medical needs.

What information must be reported on modified work form?

The modified work form must report information such as employee identification, description of modified duties, expected duration of modifications, and any medical restrictions or guidelines.