Your Company Name
Modified Work Offer
Employee:
Date:
Has Been on Modified Work Since:
Based on Medical/Physical Capabilities Form (PCF) Dated:
Physical Restrictions:
Limited:
Unable:
Modified Work Will Consist of the Following Specific Job Duties:
This Modified Work Offer Will Expire at the End of the Work Day On:
The Worker is responsible to ensure that they only do the duties listed above; The Worker is responsible to immediately
advise their Supervisor/Team Leader or Modified Work Committee Member of any concerns or issues with this program.
The Worker acknowledges that they must make all efforts to see their treating Health Care Professionals
Out-side of their regular working hours.
The Worker and the Modified Work Committee must approve any changes to the duties.
Offer Declined:
Offer Accepted:
Date:
Date:
Employee Signature
Signatures of Modified Work Committee Members:
Signature of MCM
Signature of MCM
Or:
Based on the restrictions outlined on the PCF there is No Appropriate Work Available:
Signature of MCM
Signature of MCM