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Page 1 of 2 Modified duty / return to work job offer Date: (Claimants name) (Address) (City, state & ZIP) RE: Modified duty / return to work job offer Claim no.: Injury date: Employer: Matrix Service
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How to fill out modified duty return to

01
Step 1: Obtain a copy of the modified duty return to form.
02
Step 2: Fill in your personal information such as name, employee ID, and contact details.
03
Step 3: Provide information about your modified duty assignment, including the start date, end date, and any restrictions or limitations you may have.
04
Step 4: Fill out the details of your healthcare provider or physician, including their name, contact information, and any medical recommendations they have provided.
05
Step 5: Sign and date the completed form.
06
Step 6: Submit the filled-out modified duty return to form to your supervisor or human resources department as per your organization's guidelines.

Who needs modified duty return to?

01
Employees who have been injured on the job and are unable to perform their regular duties.
02
Employees who have received medical recommendations for modified duty assignments.
03
Employers who require a record of employees returning to modified duties for documentation and compliance purposes.
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Modified duty return to is a form used to report any changes or modifications made to an employee's work duties due to medical reasons.
Employers are required to file modified duty return to for any employee who has had their work duties modified due to medical reasons.
Modified duty return to can be filled out by providing information about the employee, details of the modifications made to their work duties, and any relevant medical documentation.
The purpose of modified duty return to is to ensure that any changes made to an employee's work duties due to medical reasons are properly documented and reported.
Information such as the employee's name, date of modification, nature of the medical issue, and details of the modified work duties must be reported on modified duty return to.
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