DHS Vehicle Incident Report and Supplement to DMV Form



Temporary Transitional Work Assignment

|Date:       | | |

|Employee Name:       |Date of injury: |      |

|Your attending physician has released you for transitional work. A work assignment has been located for you which meets your restrictions. |

|Your duties will be:       |

|You will be paid your regular salary of $       . |

|You are scheduled to report for work on       and will work       hours per day. Your work days will be: |

|Monday Tuesday Wednesday Thursday Friday Saturday Sunday |

|Please note: When an assignment involves a reduction in your total work hours, if you have been on a flex schedule you will revert to a regular schedule |

|of five days per week. |

|Your work location is       . |

|Your supervisor for this assignment is       whose phone number is (     )       |

|. |

| |

|Important: If you receive this notification by mail after your report-to-work date, you should contact your transitional work supervisor at the number |

|above within 24 hours. You will be expected to report to work on your next scheduled work day. |

|If you do not report to work, it could affect the amount of time-loss compensation or other workers’ compensation benefits you receive. It could also |

|mean the loss of your right to re-employment and reinstatement. |

| |

|Supervisor’s signature: |Date:       |

|Supervisor: Please obtain the employee’s signature upon their return to work, or send this form to the employee as notification that a transitional work|

|assignment has been identified. |

|Employee signature: |Date:       |

| |

|Hand-deliver or mail to employee. After employee has signed the form, send along with the |

|physician’s release, to DHS Health & Safety, 500 Summer NE, E-22, Salem, 97301, or fax to |

|503-378-3689. Provide a copy to the employee and keep a copy in the branch or unit file. |

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