Appendix AA

RETURN-TO-WORK POLICY

ABC company has implemented a Return-to-Work Modified Duty Work Program for employees injured at work. The purpose of this program is to return an injured employee to work as soon as possible following an injury. This keeps the employee in their normal routine of working and allows the employee to be productive in some manner. Ideally an injured employee can gradually progress back to their full time position.
 
Modified duty job tasks are determined by the restrictions placed on an employee by their physician. To avoid re-injury only those tasks within the limitations must be performed by the injured employee.
 
Panel physicians are made aware of our programs and are encouraged to cooperate with ABC Company, for a smooth and safe return to work. Non-panel physicians treating employees with work related injuries shall be notified by mail to define our Return-to-Work Modified Duty Policy.
 
Upon returning to work a conference should be held with the Safety Manager, the employee’s immediate supervisor, and the injured employee. The purpose of this conference is to ensure all parties involved are aware and understand the modified duties to be performed. A “Modified Duty Job Description” form shall be signed by all attending the conference and posted as a result. Also a daily “Modified Duty Sign-off” form will be provided to the employee. The injured employee shall be asked to sign the form following their daily shift in order to ensure ABC Company has provided a modified duty job and the employee has followed his/her physician’s restrictions.
 
Modified Duty Job Description
 
Position:   Modified Duty ____________________
Location:  _________________________________
Supervisor:  _______________________________
 
General Description
 
Perform modified duty assignments within the weight and/or physical limitations prescribed by a physician, for a limited period of time. Employee must be eligible to receive Workers Compensation and must have a medical release for light duty work.
 
Responsibility/Examples of Work
 
Special Limitations
 
The Physician’s Return-to-Work Evaluation, attached, is made a part of this light duty job description and is to be strictly followed. Failure to follow any portion of this light duty job description will be considered a violation of work rules and may result in disciplinary action.
 
Special Restrictions
 
1.  _____lb. Lifting restriction
2.
3. 
4.
 
Time Limit
 
This Modified Duty job description is effective until the employee’s next visit to the physician.  It may be extended based on the physician’s report, however, extensions may not exceed ninety (90) days without authorization by _______________ Upon expiration of the time limit, the employee must have a medical release before returning  to regular duties.
 
I have read and understand the terms and conditions of this Light Duty Job Description.  If I have questions I will ask my Supervisor.
 
Date:  _______________________   Employee:  _____________________________
 
Date:  _______________________   Supervisor: _____________________________
 
Date:  _______________________   Administration:  _________________________
 
Light Duty Approved Until Next Doctor’s Examination:
 
Next Dr. Appointment:  _______________________  With:  ______________________
 
Next Dr. Appointment:  _______________________  With:  ______________________
 
Next Dr. Appointment:  _______________________  With:  ______________________
 
Modified Duty Sign Off Sheet
 
My signature acknowledges that all restrictions concerning the modified duty job I have been working have been adhered to by myself and ABC Company.
 
Name:  ___________________________  Modified duty job: _______________________
 
___Date_____      ______Signature_______       ____Date____     ____Signature_______
 
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