Instructions: Edit any information below and click "Export Word" to generate the document.
Via U.S. Mail and eSignature-
Re: DOI:
Dear {{formData.mrMs}}
,
Please find enclosed documentation detailing your modified duty work assignment. As a summary:
Location:
Start Date/hours:
Schedule:
Job Duties:
Other tasks may be assigned within physical restrictions. Tasks are self-paced, not production oriented.
Very Truly Yours,
Lowe’s Workers Compensation
(877) 219-7740
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 ___________________