Get the free modified duty information - Broome County

Brooke County Office of Risk & Insurance Management Edwin L. Crawford County Office Building / PO Box 1766 / Binghamton, New York 13902 / (607) 7782402 / FAX (607) 7786117 JEFFREY P. GRAHAM Brooke

How to fill out modified duty information

How to fill out modified duty information:

1. Start by gathering all necessary information regarding the modified duty. This may include details about the type of injury or illness, the limitations or restrictions imposed by the healthcare professional, and any recommended accommodations or adjustments in the workplace.
2. Check with your employer or Human Resources department to understand the specific procedures or forms required for documenting modified duty information. It is important to ensure that you follow the correct process and provide all requested details accurately.
3. Begin by providing your personal information, such as your name, employee identification number, and contact details, on the modified duty form. This will help in identifying the individual associated with the modified duty request.
4. Clearly state the specific injury or illness that necessitates modified duty. Include any pertinent medical information, such as the date of the incident or diagnosis, the healthcare professional's name and contact details, and any relevant medical reports or documentation.
5. Describe the limitations or restrictions imposed by the healthcare professional. This may involve outlining specific activities that you are unable to perform or modifications that need to be made to your regular job tasks or work environment.
6. If recommended by the healthcare professional, suggest any accommodations or adjustments that could facilitate your modified duty. These may include changes in work schedule, the provision of assistive devices or ergonomic adjustments, or reassignment to suitable tasks within your capabilities.
7. Ensure that you sign and date the modified duty form, indicating your agreement and understanding of the information provided. If required, ask your supervisor or manager to review and sign the form as well to acknowledge their awareness of the modified duty arrangement.

Who needs modified duty information?

1. Employees who have sustained an injury or developed an illness that affects their ability to perform their regular job duties may require modified duty information.
2. Employers and Human Resources departments need modified duty information to properly assess and accommodate the needs of employees who are temporarily or permanently restricted in their job responsibilities.
3. Healthcare professionals, such as doctors or occupational therapists, may also request modified duty information to provide appropriate recommendations and ensure the wellbeing of their patients.

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What is modified duty information?

Modified duty information is details related to the tasks and responsibilities assigned to an employee who is on modified duty due to a work-related injury or illness.

Who is required to file modified duty information?

Employers are typically required to file modified duty information for employees who are on modified duty.

How to fill out modified duty information?

Modified duty information can be filled out using forms provided by the employer or workers' compensation insurance carrier, and should include details about the employee's injury, restrictions, and assigned tasks.

What is the purpose of modified duty information?

The purpose of modified duty information is to ensure that employees who are on modified duty are provided with appropriate tasks that accommodate their restrictions and facilitate their return to full duty.

What information must be reported on modified duty information?

The information reported on modified duty information typically includes details about the employee's injury, restrictions, assigned tasks, and any accommodations provided.