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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