Instructions: The employer shall use this form to notify an employee of an offer of employment which is suitable to his/her impaired condition, as required by O.C.G.A. §34-9-240 and Board Rule 240. This form, with all attachments, must be provided to the employee and counsel for the employee at least ten days prior to the date the employee is expected to return to work. This form, along with attachments, should only be filed with the Board as an attachment to a Form WC-2.
A. Identifying Information
EMPLOYEE
EMPLOYER
B. Notice To Employee
1. This is to inform you that the following job is being made available to you pursuant to the requirements of O.C.G.A. §34-9-240 and Board Rule 240 (b):
2. A copy of the report(s) of your authorized treating physician(s), approving the job as suitable to your condition, is / are attached.
3. If you unjustifiably refuse to attempt to perform the job offered after receiving this notification or if you attempt the job for less than eight cumulative hours or one scheduled work day, whichever is greater, the employer/insurer shall be authorized to suspend payment of income benefits to you effective the date you are scheduled to report to work. Should you attempt but fail to continue working for fifteen (15) scheduled work days, your income benefits shall immediately be reinstated.
4. If you have any questions about the job being offered to you, you may contact the employer at: [[wc240.employerContactName]], [[wc240.employer]].
C. Certificate of Service