Get the free MODIFIED DUTY FORM - WRHA Professionals

MODIFIED DUTY FORM TO BE COMPLETED BY HEALTHCARE PROVIDER ONLY if there has been a change in patients abilities. WHA will pay up to $25.00 for the COMPLETED form. Completed forms can be faxed to WHA

How to fill out modified duty form

How to fill out modified duty form

1. Before filling out the modified duty form, gather all the necessary information such as the employee's name, job title, and start date of modified duty.
2. Start by filling out the employee's personal information section, including their name, address, phone number, and email.
3. Next, provide details about the modified duty, such as the specific tasks or responsibilities assigned to the employee during this period.
4. Indicate the start and end dates of the modified duty period, including any extensions if applicable.
5. If there are any medical restrictions or limitations for the employee, clearly state them in the appropriate section of the form.
6. Ensure that both the employee and their supervisor sign the form to acknowledge their understanding and agreement to the modified duty arrangements.
7. Submit the completed form to the appropriate department or person responsible for managing employee records.
8. Keep a copy of the filled-out form for your records.
9. If any changes occur during the modified duty period, update the form accordingly and notify the relevant parties.
10. Periodically review the employee's progress and reassess if any modifications to the modified duty arrangement are needed.

Who needs modified duty form?

1. The modified duty form is generally required for employees who have experienced temporary work-related injuries or illnesses that prevent them from performing their regular job tasks.
2. Employers often utilize modified duty programs to provide alternative temporary assignments for injured or ill employees as part of their return-to-work initiatives.
3. This form helps document the details of the modified duty arrangements and ensures that both the employee and employer are aware of their responsibilities and obligations during this period.
4. The form may also be required by insurance companies or workers' compensation agencies to support claim processing and evaluation of appropriate benefits.

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What is modified duty form?

Modified duty form is a document that outlines the tasks and responsibilities that an employee can perform while recovering from an injury or illness.

Who is required to file modified duty form?

Employers are required to file the modified duty form for employees who are unable to perform their regular job duties due to a medical condition.

How to fill out modified duty form?

The modified duty form should be filled out by the employer with the help of the employee and the healthcare provider. It should include details about the employee's restrictions, limitations, and recommended accommodations.

What is the purpose of modified duty form?

The purpose of the modified duty form is to ensure that injured or ill employees are given appropriate accommodations to help them recover and return to work safely.

What information must be reported on modified duty form?

The modified duty form should include the employee's medical restrictions, limitations, recommended accommodations, and the healthcare provider's recommendations.