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ModifiedDutyandReturntoWorkForm (DonotuseforshiftFirefighters.) (patient/employee name)wasevaluatedon (date). Complete section(a)belowiftheemployeedoesnothaverestrictions (a) Returntofullactivitiesatworkwithoutrestrictionson

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How to fill out modified duty and return

01

To fill out modified duty and return form, follow these steps:

02

Start by entering your personal information such as name, employee ID, and contact details.

03

Specify the date when you are requesting modified duty and return.

04

Provide a brief explanation of your current medical condition or injury that prevents you from performing your regular job duties.

05

Indicate the restrictions or limitations you have and any specific accommodations or modifications you require in order to perform modified duties.

06

Attach any relevant medical documents or reports that support your request.

07

Sign and date the form to certify the accuracy of the provided information.

08

Submit the completed form to the appropriate department or person in your organization responsible for handling modified duty and return requests.

09

Keep a copy of the filled form for your records.

Who needs modified duty and return?

01

Modified duty and return is typically needed by employees who have suffered a temporary medical condition or injury that hinders their ability to perform their regular job duties.

02

This can include individuals who are recovering from surgery, experiencing an illness, or have a physical limitation or impairment that restricts their work abilities.

03

Modified duty and return allows these employees to continue working in a capacity that accommodates their current condition, ensuring a smoother transition back to their regular job once they have fully recovered or improved.

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What is modified duty and return?

Modified duty and return refers to a form that must be filled out by employees who are returning to work after being on modified duty due to a work-related injury.

Who is required to file modified duty and return?

Employees who have been on modified duty due to a work-related injury are required to file modified duty and return.

How to fill out modified duty and return?

Modified duty and return form can be filled out by providing details about the employee's work restrictions, accommodations needed, and expected return date.

What is the purpose of modified duty and return?

The purpose of modified duty and return is to ensure that the employee can safely return to work while accommodating any work restrictions they may have due to a work-related injury.

What information must be reported on modified duty and return?

The modified duty and return form must include details about the employee's work restrictions, accommodations needed, and expected return date.

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