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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 form can be faxed to employee\'s

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How to fill out modified duty form

01

Obtain the modified duty form from your HR department or supervisor.

02

Fill in your personal information such as name, employee ID, and contact details.

03

Provide details about your injury or medical condition that necessitates modified duty.

04

Specify any restrictions or limitations you have in relation to your regular job duties.

05

Get the form signed by your healthcare provider or physician, if required.

06

Submit the completed form to your HR department or supervisor for review and approval.

Who needs modified duty form?

01

Employees who have sustained an injury or developed a medical condition that prevents them from performing their regular job duties may need to fill out a modified duty form.

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What is modified duty form?

Modified duty form is a document used to outline and specify the tasks that an employee can perform while recovering from an injury or illness.

Who is required to file modified duty form?

Employers are typically required to file modified duty forms for employees who are unable to perform their regular job duties.

How to fill out modified duty form?

To fill out a modified duty form, employers should include details about the employee's restrictions, the specific tasks they can perform, and any accommodations that may be needed.

What is the purpose of modified duty form?

The purpose of a modified duty form is to facilitate the return-to-work process for employees who are recovering from an injury or illness.

What information must be reported on modified duty form?

The modified duty form should include the employee's name, job title, restrictions, tasks they can perform, accommodations needed, and any other relevant details.

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