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Victoria General Hospital-Modified Duty Form February 29, 2012, For Planning Early and Safe Return to Work Name of Employee: Position: Nature of Illness/Injury: (specific Diagnosis should not be provided)

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What is modified duty form?

The modified duty form is a document used to outline specific job tasks that an employee can perform while recovering from an injury or illness.

Who is required to file modified duty form?

Employers are usually responsible for filing the modified duty form for employees who need accommodations due to an injury or illness.

How to fill out modified duty form?

To fill out the modified duty form, employers must detail the specific tasks the employee can perform, the restrictions they have, and any accommodations needed.

What is the purpose of modified duty form?

The purpose of the modified duty form is to ensure that employees can continue working in a safe and productive manner while recovering from an injury or illness.

What information must be reported on modified duty form?

The modified duty form must include details on the employee's restrictions, accommodations needed, and the specific tasks they can perform.

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