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Facilities Management Acknowledgement of Light Duty Restrictions and Assignments I understand that I must follow all light duty restrictions set forth by my physician. The restrictions are as follows:

How to fill out acknowledgement of light duty

How to fill out acknowledgement of light duty:

1. Begin by entering your name and contact information at the top of the form, including your full name, address, phone number, and email address.
2. Read the terms and conditions section carefully. This section typically outlines the expectations and responsibilities associated with light duty, such as the specific tasks or restrictions that may be imposed.
3. Sign and date the acknowledgement form at the designated area. By signing, you are acknowledging that you understand and agree to comply with the terms of the light duty assignment.
4. If applicable, have your supervisor or manager also sign and date the form. This confirms that they have reviewed the light duty assignment with you and are aware of your responsibilities.
5. Make a copy of the completed acknowledgement form for your records. It's important to keep a copy for future reference, especially if any questions or issues arise regarding your light duty assignment.

Who needs acknowledgement of light duty?

1. Employees who have been placed on light duty due to a work-related injury or medical condition may be required to fill out an acknowledgement of light duty. This form serves as a confirmation that they understand the specific tasks or restrictions associated with their light duty assignment.
2. Employers also benefit from having employees fill out this acknowledgement form, as it helps ensure that both parties are on the same page regarding the expectations and responsibilities of the light duty assignment.
3. It is important for both the employee and the employer to have a written record of the acknowledgement, as it can be used as evidence of compliance or understanding in case of any disputes or questions in the future.

For pdfFiller’s FAQs

What is acknowledgement of light duty?

Acknowledgement of light duty is a form that an employee signs to confirm their understanding and acceptance of a modified work assignment due to a temporary physical restriction.

Who is required to file acknowledgement of light duty?

Employees who have been assigned to light duty work by their employer are required to file acknowledgement of light duty.

How to fill out acknowledgement of light duty?

Employees should carefully read the form, provide their personal information, sign the document, and return it to their supervisor or HR department.

What is the purpose of acknowledgement of light duty?

The purpose of acknowledgement of light duty is to ensure that employees understand their temporary work assignment, restrictions, and obligations.

What information must be reported on acknowledgement of light duty?

The acknowledgement of light duty form typically includes employee's name, job title, start date of light duty, restrictions, and duration of the assignment.

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