Fillable INJURED EMPLOYEE CHECKLIST MODIFIED DUTY PROGRAM

Fill Online, Printable, Fillable, Blank INJURED EMPLOYEE CHECKLIST MODIFIED DUTY PROGRAM Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

INJURED EMPLOYEE CHECKLIST MODIFIED DUTY PROGRAM

On average this form takes 5 minutes to complete

The INJURED EMPLOYEE CHECKLIST MODIFIED DUTY PROGRAM form is 2 pages long and contains:

  • 0 signatures
  • 15 check-boxes
  • 11 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
INJURED EMPLOYEE CHECKLIST
MODIFIED DUTY PROGRAM
is the person designated as your contact
person in Administration or Human Resources.
Telephone number:
Modified duty is a temporary placement in a position that can accommodate your
limitations/restrictions resulting from your work related injury. The job
assignments are temporary in nature and you may be asked to move to another job
or location as the need arises.
While on modified duty, you will be asked to keep both your supervisor and your
employer’s designated contact person informed of your work status. This means
that both individuals should be contacted following each visit to your treating
physician.
The person that you report to in your modified duty assignment should be kept
informed (in advance) of all scheduled appointments so that the workload can be
appropriately assigned.
If you have been asked by the supervisor of your temporary job to do something
outside your restrictions, you must remind the supervisor of your restrictions –
DO NOT participate in any work activity that is outside of the restrictions placed
on you by your treating physician. If you are experiencing pain or other problems
as a result of the work you have been asked to perform, contact your physician
and report the problems to the employer’s designated contact person immediately.
If you are unable to report to work for any reason, you must contact the supervisor
of the area where you have been temporarily assigned, as well as the employer’s
designated contact person before the beginning of your scheduled shift.
Attendance expectations do not change while in a modified duty position.
While on modified duty, you will continue to receive your same rate of pay,
regardless of the type of work you are asked to do. If your normal shift is
evenings/nights/weekends where you normally receive differential pay, we will
continue to pay you base rate plus differential while on modified duty, even if you
are working the day shift. Our goal is to allow you to continue to receive your
normal pay. If you were receiving differential pay, please indicate this on your
time sheet so that we can assure that you are paid correctly.
If you have been released to work only part-time by your treating physician and
your normal schedule is full-time, you will be offered modified duty that meets
the part-time restrictions from your physician. You will be eligible to receive a
“temporary partial disability” payment from workers’ compensation for the
remaining missed wages. This not direct dollar-for dollar compensation but is
pro-rated based on New Mexico State Workers’ Compensation Statutes. For
more information regarding “temporary partial disability”, please contact your
claims adjuster (your employer’s designated contact person can provide you with
the name and telephone number of your adjuster)
You are not required to work modified duty. This is offered to you as an
alternative so that you can continue to receive your full salary while you are
recuperating from your work-related injury. You have the option of remaining at
home and being placed on a leave of absence. However, you need to be aware
that if there is work available to you and you choose to remain off work, you will
not receive any compensation for lost wages through workers’ compensation.
If you have problems in your modified duty assignment, you may ask to be
reassigned to a different area. Please contact your employer’s designated contact
person
From time to time, medical case managers will be assigned to facilitate your
medical care and treatment plan. Medical case managers are generally assigned
when there are complicating factors (i.e., multiple injuries, surgery, unusual
diagnoses, long courses of treatment, etc.)
Modified duty assignments (in combination with any missed work time) will be
available for up to __ weeks/months. Modified duty does not extend past __
weeks/months. If at the end of __ weeks/months you are unable to return to your
previous position, you may request a leave of absence for an additional __
weeks/months. If you have been employed for one year and have worked a
minimum of 1040 hours in the previous year, you are entitled to a job-protected
leave of absence for up to 12-weeks. If you are unable to transfer to a position
that meets your qualifications and your work-related restrictions before the end of
the 12-week period, your employment will be terminated.
If during the __ weeks/months of modified duty you reach maximum medical
improvement (MMI), and you are not able to return to your previous position, you
will be granted up to __ weeks/months to locate another position in the
organization. However, the combination of pre-MMI modified duty and post-
MMI modified duty cannot last more than __ weeks/months.
I, the employee, have accepted the agreement.
I, the employee, do not accept the agreement.
Employee Signature Date
Employer Representative Signature Date
Weeks
Months
Months
Months
Weeks
Weeks
Weeks
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

INJURED EMPLOYEE CHECKLIST MODIFIED DUTY PROGRAM

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document