NOTICE TO RETURN TO MODIFIED DUTIES
Notice - Return to WorkThis letter is sent to employees to notify them that they have been released to return to work. The letter includes all information necessary to defend a termination petition should the employee not return to work as ordered by this letter. If the employee voluntarily returns to work, this letter is not required.Dear [EMPLOYEE]:We received the results of the independent medical examination conducted on [DATE] by Dr. [NAME]. Based on the examination, you have been released to return to your regular, unrestricted job duties of a [JOB CLASSIFICATION NAME].You are, therefore, ordered to return to work on [DATE] and report to [LOCATION], [SUPERVISOR NAME] at [TIME]. Your salary effective [RETURN TO WORK DATE] is $[RATE]. Failure to report to this assignment could jeopardize your workers’ compensation indemnity benefits. In addition, you could receive discipline up to and including termination if you do not return to work. If you have questions concerning this information, please contact me at [ADDRESS AND/OR TELEPHONE].Sincerely,WC CoordinatorEnclosure: Bureau of Workers’ Compensation Formcc: Inservco Insurance Services, Inc.SupervisorNote: This work-related injury does not indicate and should not be interpreted to indicate that you are regarded by the commonwealth as having a disability as defined by the ADA. ................
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