Fillable WC Modified Duty Form IN YOUR E-MAIL REPLY, PLEASE INDICATE IF THE EMPLOYEE ACCEPTED OR DECLINED

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WC Modified Duty Form IN YOUR E-MAIL REPLY, PLEASE INDICATE IF THE EMPLOYEE ACCEPTED OR DECLINED

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7/2014
IN YOUR E-MAIL REPLY, PLEASE INDICATE IF THE EMPLOYEE ACCEPTED
OR DECLINED.
PLEASE HAVE THE EMPLOYEE SIGN/DATE THIS DOCUMENT AND EMAIL
vaaron@littlerock.org or FAX TO 501-244-5475 Attn: Rachel Aaron
Name:__________________________________________________________
SSN: _________________
Dept: ______________
Date of Injury: ______________
Date Injury Reported: ______________
Medical Facility: _____________
Date Evaluated: __________________
Released for Modified Duty: _____________
Medical Restrictions: _____________
Date Modified Duty Offered: ______________
Accepted: ________________
Declined: ________________
Employee Signature ___________________________ Date: ______________
I UNDERSTAND THAT IF I ELECT TO DECLINE AVAILABLE MODIFIED DUTY
MY LOST TIME WILL BE CHARGED TO MY AVAILABLE LEAVE. IF I HAVE NO
LEAVE AVAILABLE, MY TIME WILL BE CHARGED TO AUTHORIZED LEAVE
WITHOUT PAY.
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WC Modified Duty Form IN YOUR E-MAIL REPLY, PLEASE INDICATE IF THE EMPLOYEE ACCEPTED OR DECLINED

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Completed 21 March 2020

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