Date of injury

Name of Doctor

Date to start light /modified work duties
Date of return to regular work duties

The ASL return to work program is intended for transitional return to pre-injury duties within a fixed duration. In the event that an employee is injured while at work, ASL will make every effort to ensure that the injured employee is able to return to work in a timely and safe manner.
If unable to perform regular duties, the employee will be offered modified duties as allowed per any medical constraints outlined by the employee’s health care provider. Please review offer of modified duties discussed with Foreman/Supervisor and decide to either accept or reject the offer. If accepted, please sign

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.