Information
-
Document No.
-
Audit Title
-
Client / Site
-
Conducted on
-
Prepared by
-
Location
-
Personnel
-
Todays Date
-
Date of Injury
-
Dear _________________________________________________, Your physician, Dr. _________________________________, has released you for modified work on ______________________ with the following restrictions:_________________________________________________________________________________________. We have located a position for you based on these restrictions. Attached is a copy of the _____________________________release for your reference. If these restrictions change at any time it is imperative that you inform Joe Visgaitis, Safety Manager, at 571-233-1691 immediately. Your position will be as follows: Job Title:___________________________________________________________________ Duration: Up to ninety (90) days-subject to review Job tasks:___________________________________________________________________ You will be receiving your regular pay per hour. We ask that you report for work on: Date:_________________________ Hours per week: 8 Time:_________________________ Days per week: 5 Location:______________________ Duration: Subject to periodic review and can not exceed ninety (90) days. Phone:________________________ If you receive this letter on or after the day you are to report to work, please contact our office immediately and report to work within 24 hours from the date you receive this letter. Failure to report to work could affect your time loss compensation, vocational eligibility and/or re-employment/reinstatement rights. We look forward to seeing you and wish you a speedy recovery. _________________________________________________________ _______________________________________ Employee's Signature Date I accept this as you offered: Yes_____________ No______________ ___________________________________________________________ ________________________________________ Worker's Signature Date
