Texas Tech University
Physical Plant
ALTERNATE/LIGHT DUTY NOTIFICATION
For TEMPORARY DISABILITY
Indicate in the spaces provided either LIGHT DUTY or ALTERNATE DUTY.
LIGHT DUTY
ALTERNATE DUTY
EMPLOYEE AGREEMENT
I understand I have been placed under alternate/light duty. I further understand that I am to adhere strictly to all
physician orders, and to all Texas Tech University and Physical Plant policies regarding alternate/ light duty.
Signature
Date
DEPARTMENT APPROVAL
Acceptance of employee for Alternate/Light Duty
YES
NO
YES
NO
If denied, reason:
Position available in same department?
Department hosting position for injured party:
Temporary Supervisor:
Date
Home Department Director Signature
ALTERNATE/LIGHT DUTY ASSIGNMENTS
1st Four Weeks
Effective Date
Termination Date
2nd Four Weeks
Effective Date
Termination Date
3rd Four Weeks
Effective Date
Termination Date
Approvals
1st Four Weeks
Home Department Director
Hosting Department Director
2nd Four Weeks
Home Department Director
Hosting Department Director
3rd Four Weeks
Home Department Director
Hosting Department Director
Attachment A
PP/OP 02.03
12/10/2010