Instructions: Edit any information below and click "Export Word" to generate the document.
Mailed via USPS Mail and eSignature
Re: DOI:
Dear
,
We have been notified that your physician, Dr.
,
has released you to return to work with physical restrictions as of
.
We have matched these restrictions with a temporary, modified duty job assignment at a local nonprofit organization. This assignment will allow you to remain working, within your restrictions, as you progress towards a release to full duty.
You are scheduled to report for temporary transitional duty work at
,
on
.
You are scheduled for an acquaintance meeting on
.
You will report to
.
Your schedule will be
(not to exceed 8 hours in any workday, or 40 hours per week).
The job
will pay your
regular pre-injury wage.
A weekly timesheet
will be prepared by your
nonprofit supervisor
who will have you sign it so
they can fax it for
payroll processing.
Directions to the job site are attached. Should you need to let someone know that you will be late or will not be coming to work, please be sure that you notify me. [[formData.dressCode]] Apparel should be neat, clean, modest, and not display any unprofessional or offensive content. Closed toe shoes are required.
Your modified job duties will consist of the following:
.
Other tasks may be assigned within physical restrictions. Tasks are self-paced, not production oriented.
If necessary, we will work with you and your physician to modify the job duties to meet any limitations as you work towards a full-duty release. We also will accommodate your medical and/or physical therapy appointments.
All Lowe’s policies, including attendance, tardiness, and calling off work will apply to you during this program. You will continue to be covered under Lowe’s Workers’ Compensation policy. We expect that you will report for this position as requested. Please contact me if there are any issues with your ability to report.
Very truly yours,
Lowe’s Workers’ Compensation
877-219-7740
Enclosures (3): Job Description, Program Description, Driving Directions
Cc:
Cc: Claimant Attorney:
Program Acceptance/Refusal
Please check appropriate box indicating your acceptance or declination of this modified duty assignment
☐ I, [[formData.employeeName]], have received and accept the light/transitional duty offer:
-OR-
☐ I, [[formData.employeeName]], refuse the modified duty assignment:
Employee Signature _____________________________________________________
Date ___________________