Get the free Modified Duty Form

Complete this form to facilitate a safe return to work with specified duties based on healthcare provider recommendations and employee capabilities.

How to fill out modified duty form

How to fill out modified duty form

1. Obtain the modified duty form from your HR department or workplace website.
2. Read the instructions carefully provided on the form.
3. Fill in your personal information such as name, employee ID, and department.
4. Specify the reason for requesting modified duty, including any medical recommendations.
5. Indicate the type of modified duties you believe you can perform.
6. Include any supporting documentation from your healthcare provider if required.
7. Review the completed form for accuracy and completeness.
8. Submit the form to your supervisor or HR for approval.

Who needs modified duty form?

1. Employees who are recovering from an injury or illness and require temporary adjustments to their work responsibilities.
2. Workers who have been advised by their healthcare provider to limit certain activities.
3. Individuals returning to work after a medical leave of absence.

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What is modified duty form?

A modified duty form is a document used to report and request adjustments to an employee's work duties or responsibilities, typically due to disability or recovery from an injury.

Who is required to file modified duty form?

Typically, employers or their representatives are required to file the modified duty form for employees who are unable to perform their regular job duties due to medical or health-related issues.

How to fill out modified duty form?

To fill out a modified duty form, provide the employee's personal information, describe the nature of the injury or condition, outline the modified duties the employee can perform, and obtain necessary signatures from relevant parties.

What is the purpose of modified duty form?

The purpose of the modified duty form is to document the temporary adjustment of an employee's job responsibilities to accommodate their recovery process while still allowing them to contribute to the workplace.

What information must be reported on modified duty form?

The modified duty form must report the employee's details, the medical condition or injury, the proposed modified duties, expected duration of modifications, and any required medical documentation.