Return to Work Survey Highline Produce Ltd. S-F-031RTW Survey

• Site conducted

  Select

• Conducted on

  Date

• Conducted By

• Associate Name

• Associate Department at Time of Injury

• Duration of Modified Work

• Date of Injury

  Date

• Date RTW Plan Ended

  Date

• Modified work was offered to me from the onset of my report of<br>illness/injury

  Yes

  No

  N/A

• The RTW process was explained to me at the beginning so that I<br>could understand what I should expect to happen at each stage of<br>the process.

  Yes

  No

  N/A

• The modified work plan was developed with my specific needs in<br>mind

  Yes

  No

  N/A

• I felt I was part of the plan development process at all stages and<br>had the opportunity to agree or disagree with the plan as proposed

  Yes

  No

  N/A

• There was open communication between myself and members<br>of the HR team during the plan

  Yes

  No

  N/A

• There was open communication between myself and my<br>supervisor(s) during the plan

  Yes

  No

  N/A

• I felt that the RTW process was as easy and smooth as possible

  Yes

  No

  N/A

Comments, Concerns and Suggestions

• Comments:

Signatures

• Associate Signature

  Sign

• Surveyor Signature

  Sign