MAD-Notice/Temporary Modified Offer of Employment

NOTICE OF MODIFIED OFFER OF EMPLOYMENT

• Todays Date

  Date

• Date of Injury

  Date

• Dear:

• Your doctor has released you to modified duty on:

• Select date

  Date

• Doctor's Name:

• With the following restrictions:

• We have located a position for you based on these restrictions. Your position will be as follows:

• Job Title:

• You will be receiving your regular pay per hour. We ask that you report for work on:

• Select date

  Date

• Hours per day:

• Days per week:

• Location:

• Phone Number:

• Duration: Up to 90 days, subject to review.
  
  If you receive this letter on or after the day you are to report to work, please call 703.834.5570 immediately and request to speak to the safety department and to report to work within 24 hours after receiving this letter.
  
  Failure to report to work could affect your time loss compensation, vocational eligibility, and/or employment/reinstatement rights.
  
  We look forward to seeing you and wish you a speedy recovery!

• Employee Signature:

  Sign

• Employer Representative Signature:

  Sign