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RETURN TO WORK RELEASE /MODIFIED DUTY FORM Today s Date: Employee Name: Department: Supervisor s Name: INSTRUCTIONS AND REQUIREMENTS 1. Physician completes Section A. & Section B., if Transitional

How to fill out modified duty form-non-work relatedpdf

How to Fill out Modified Duty Form-Non-Work Related PDF:

1. Start by obtaining the modified duty form. This form is typically provided by your employer or human resources department. If you are unable to find the form, reach out to your HR representative or supervisor for assistance.
2. Read the instructions carefully. The modified duty form will usually come with instructions that guide you through the filling process. Take the time to understand the requirements and any documentation or information that may be needed.
3. Provide your personal information. The form will typically ask for details such as your name, employee ID or social security number, contact information, and the date on which the form is being filled out. Fill in these details accurately and legibly.
4. Describe the nature of the non-work-related injury or condition. In this section, you will need to provide a brief description of the injury or condition that is preventing you from performing your regular job duties. Be as specific as possible, detailing any doctor's diagnoses or medical reports if required.
5. Indicate the expected duration of modified duty. Specify the expected length of time you will require modified duty due to the non-work-related injury or condition. This could be a set number of days, weeks, or months. It is crucial to consult with your healthcare provider to determine a realistic timeline.
6. Attach any relevant medical documentation. Depending on your employer's policies, you may need to submit medical documentation supporting your non-work-related injury or condition. This can include doctor's notes, medical reports, or any other relevant documentation. Make sure to attach these documents securely to the form.
7. Request any accommodations or modifications needed. If you need any specific accommodations or modifications to perform modified duty, clearly state them in this section. For example, you may require lighter duties, reduced working hours, or the use of assistive devices. Provide any necessary details to ensure accurate consideration.
8. Sign and date the form. Always sign and date the form at the designated location to validate it. By doing so, you are confirming that the information provided is accurate and complete to the best of your knowledge.

Who Needs Modified Duty Form-Non-Work Related PDF?

1. Employees who have experienced a non-work-related injury or condition that prevents them from fulfilling their regular job duties may need to fill out a modified duty form. This could include individuals who have sustained injuries outside of work or developed medical conditions that make their current job tasks challenging.
2. Employers use the modified duty form to assess the need for accommodations or modifications and to ensure that employees are provided with suitable work during their recovery period. By completing the form, employees can communicate their limitations and specific needs related to modified work assignments.
3. It is important to consult with your employer or human resources department to understand their specific procedures regarding the use of the modified duty form. They will be able to provide you the necessary information and guide you through the process to ensure a smooth and efficient experience.

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What is modified duty form-non-work relatedpdf?

Modified duty form-non-work relatedpdf is a form used to document any changes in an employee's duties or responsibilities that are unrelated to work.

Who is required to file modified duty form-non-work relatedpdf?

Employees who will be taking on modified duties due to non-work related reasons are required to file the form.

How to fill out modified duty form-non-work relatedpdf?

The form should be filled out by the employee, signed by the supervisor, and submitted to the appropriate department.

What is the purpose of modified duty form-non-work relatedpdf?

The purpose of the form is to ensure that any changes in an employee's duties are properly documented and approved.

What information must be reported on modified duty form-non-work relatedpdf?

The form should include the employee's name, date of modification, reason for modification, and any relevant details about the new duties.