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Return to Work Program Agreement
| Participant Name: | ||
|---|---|---|
| Date of Injury: | ||
| Claim: | ||
| Employer: | ||
| Nonprofit (NPO): | ||
| Start Date: |
I, [[formData.employeeName]], understand that I remain an employee of [[formData.jobSiteName]] while performing modified duty for the, nonprofit (NPO) facility: [[formData.npoName]], This work will be done virtually. I understand this position is temporary and will not result in a permanent position with [[formData.npoName]]. I understand that I will continue
to be covered under
Workers’ Compensation program
while in this program
and agree to adhere
to all
[[formData.jobSiteNamePlural]]
HR policies and procedures, including attendance, personal/vacation days, and calling off work.
I will be working
.
I understand that any requests to change this schedule need to be submitted, in advance, by the NPO supervisor to the TWS Coordinator for approval by [[formData.jobSiteName]]. I understand that this schedule will not be altered unless approval is granted by [[fornData.jobSiteName]]. I will not work any additional hours over the scheduled hours as outlined in the light duty offer letter. I understand overtime is not approved while working in this temporary, transitional duty program. If I cannot work, will be late, or will miss time for any reason I agree to notify the NPO supervisor in advance.
I have been loaned the equipment necessary to complete my assigned tasks, including a tablet with protective case, headset, mouse, and keyboard. I will treat this valuable equipment with care and return per provided instructions in the condition that it was received at the conclusion of this assignment. Should this equipment not be returned within fourteen days of completing this assignment, I may be billed for these materials.
I will be logging my hours worked via provided electronic tablet daily. I understand it is my responsibility to make sure the time card is electronically signed and approved by both myself and my charity supervisor and submitted electronically each week by the deadline indicated. I understand both the electronic signature of the nonprofit supervisor and myself is required for submission and processing to confirm the timecard’s accuracy.
I agree to abide by the physical restrictions as outlined by my authorized medical provider at all times while performing virtual modified duty and understand I will not be expected to perform duties outside of these restrictions. During the program, I understand that I am expected to communicate all changes in my physical restrictions to my employer/adjuster immediately and to submit appropriate documentation of these changes.
Participant: ______________________________________________________________ Date: _______________
NPO Representative: _____________________________________________________ Date: _______________
Please return on participant’s first day.
NPO: Please maintain a copy of this document once signed on site for your file as reference.