Modified Duties Offer Form* - SmartSimple



|Modified Duties Offer Form* |

*not required for Incident; required for most Medical Aid claims and is required for all Lost Time claims

|Employee Name: |Employee #: |

|Position: |Store # / Location: |

|Area of the Body Injured: | |

|Manager: | |

Message to the Manager:

• This document should be used to offer modified work in order to allow employees to continue working while recovering from injuries or illnesses. The employee has the right to decline this offer.

• Please attach the “Functional Abilities Form” or “Form 8” that has been completed by the Health Care Provider. In the absence of documentation outlining restrictions and abilities, please offer tasks within standard medical precautions for the injured body part. For guidance you can refer to the Modified Duty Database available on the Store Portal.

Message to Employee:

• Modified Work is a temporary, goal directed rehabilitative measure and does not represent a permanent change of duties/responsibilities. Your activities should progress gradually toward full duties. To this end, regular medical updates will be requested from you to obtain from your Health Care Provider.

• You are advised to alternate between tasks assigned to you and take frequent short breaks. This will help to prevent overexertion of any one particular muscle group.

• You are responsible to work within the restrictions and limitations outlined below. If you are asked by a co-worker to do something that is not within those restrictions/limitations, explain your precautions and ask him/her to seek assistance from your Manager.

• Any change in the hours or duties worked must be discussed with your Manager.

If you are unable to attend work for any reason, must leave work early, or experience any problems or difficulties, please advise your Manager immediately.

|Hours of Work (regular or otherwise specified): |

|Restrictions/Limitations: |Modified work assignments and specific duties to be performed: |

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This offer of modified duties is available (date) From: ________________ To: ________________

(usually no more than 2 weeks)

❑ Modified Work Offer Accepted

❑ Modified Work Offer Declined

Employee Signature (optional): _______________________________________ Date: ____________

Managers’ Signature (required): ______________________________________ Date: ____________

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