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Our purposes are to facilitate recovery prevent deterioration of work skills demonstrate concern minimize loss of human resources and reduce costs. MODIFIED DUTY WORK FORM EMPLOYEE S NAME The Town of Vienna provides short-term modified duty for employees who are temporarily disabled by occupational injuries. Because of the varied work activities some type of work can usually be found to meet the injured employees capabilities. RESTRICTED WORK BASED ON YOUR TREATING PHYSICIAN S RECOMMENDATIONS...
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How to fill out modified duty work form
How to fill out modified duty work form
01
Read the modified duty work form carefully.
02
Provide your personal information such as name, employee ID, and contact details.
03
Specify the reason for modified duty, including any medical conditions or occupational injuries.
04
Include the date when the modified duty will begin and end.
05
Indicate the specific tasks or responsibilities that you will be able to perform during this period.
06
Obtain signatures from both your supervisor and a healthcare professional.
07
Submit the filled-out form to the appropriate department or human resources.
08
Keep a copy of the form for your records.
Who needs modified duty work form?
01
Employees who have experienced a medical condition or occupational injury that prevents them from performing regular duties.
02
Workers who have been advised by a healthcare professional to take on modified duties as part of their recovery process.
03
Employers who need a documented record of modified duty requests and accommodations provided.
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