Appendix Y


This program is to minimize the production lost by the company and wages lost by the employee as a result of temporary partial incapacity resulting from on the job injury.  It is the express intent to provide modified duty within the employee’s restrictions whenever possible and to facilitate the employees full rehabilitation as rapidly as possible.
The Human Resources Director is primarily responsible for administration of this procedure.
  1. Notification of Restriction
    1. Human Resources will be notified that an employee has been injured.
    2. Copy of completed Treatment Report will be furnished to Human Resources immediately after treatment; if after office hours, a copy will be left in the Supervisor’s office and furnished to Human Resources the next business morning.
    3. In the event the injured employee cannot return to the facility due to hospitalization or similarly severe prescribed restriction, Human Resources will obtain required information directly from the medical resources.
    4. The Treatment Report is the primary document to capture the treating physician’s restrictions. Additional clarification or modification of restriction may be provided on other documents; however, a Treatment Report will be taken by the employee to all medical appointments (except physical therapy).
    5. Restrictions addressed by this policy must be identified by a medical doctor or other state licensed practitioner of the healing arts.
  2. Identification of Modified Duty Job Assignment(s)
    1. In cases where an employee’s restrictions preclude performing his pre-injury job (or particular aspect of the job), every reasonable effort will be made to identify or create a productive job assignment which will accommodate temporary restrictions as identified by the treating physician.
      1. This accommodation may include providing intermittent assistance or relief in dealing with one or more elements of the employees “regular” (pre-injury) job.
      2. Accommodation may also include arrangements for less than an eight hour work day (in such cases, hours not worked will be accumulated and submitted to the worker’s compensation insurance carrier).
      3. Every effort will be made to place the employee in the most productive assignment available; direct labor categories will be preferred over indirect.
      4. The modified duty job assignment will be made by the Human Resources Director after consultation with production management.
    2. The modified duty job assignments will be recorded on the Restricted Job Description, to be completed by Human Resources prior to or coincidental with the employee’s return to work.
      1. The Description will be acknowledged by the employee, supervisor, union representative and the Human Resources Director. Each will be provided a copy of the completed document.
      2. The Description may be revised or reissued based on change in the employee’s restrictions. The Description will expire 90 days after last authorization or when employee is released without restrictions.
      3. It is the Supervisor’s explicit responsibility not to assign any work to the employee which is contrary to the identified restrictions. The employee has an explicit responsibility not to attempt any task which may exceed his identified restrictions. Any difficulties experienced by the employee within his restrictions will be reported to Human Resources for review with treating physician.
      4. Any questions or controversy as to an employee being restricted from performing specific task(s) will be brought to the immediate attention of the Human Resources Director for resolution.
      5. The Human Resources Director will notify all parties when the employee has been fully released for unrestricted duty.
    3. Wages and Related Considerations
      1. The employee will continue to receive his/her pre-injury wage, plus any general increases, for all hours worked in a restricted capacity.
      2. The employee will be paid per C.1 for hours less than his/her scheduled shift lost due to company arranged examinations, treatment and therapy.
      3. The employee may not bid on any posted job openings while in a restricted capacity.
      4. The employee will be shown on the weekly schedule as “restricted.”
      5. Since he will “follow the work” within restrictions, normal shift scheduling practices may not be possible.


Position:  Modified Duty ______________________________________________________
General Description:  Performs restricted duty assignments within the weight and/or physical limitations prescribed by a provider.  Employee must be eligible to receive workers’ compensation benefits and must have medical release for restricted duty.
Responsibilities/Examples of Work:
Special Limitations:  The provider’s release attached is made a part of this light duty job description, and is to be strictly followed.  Failure to follow any portion of these descriptions will be considered a violation of work rules and may result in disciplinary action.  Any questions regarding the appropriateness of a work assignment must be brought to the immediate attention of Human Resources.
Specific Restrictions:
1. ____ lb. lifting restriction
Time Limit:  The Restricted Duty job description is effective until the employee’s next visit to the provider.  It may be extended based on the provider’s report, however extensions may not exceed ninety (90) days without authorization by Human Resources.
I have read and understand the terms and conditions of the Restricted Duty Job Description.  If I have questions I will ask my Supervisor; any differences in interpretation will be brought to the attention of Human Resources.
Date:  _________________________________  Employee:  _______________________
Date:  _________________________________  Supervisor: _______________________
Date:  _________________________________  Union:  __________________________
Date:  _________________________________  Human Resources: _________________
Dr. Appointment:  _______________________  With:____________________________
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