We have received your current work status report from:
We are able to accommodate the above restrictions. Your modified duty assignment will begin on:
* This modified duty assignment is not to exceed 90 days or until restrictions change or when employee is released to full duty by his/her treating physician, whichever occurs first.* If employee is not released to full duty within 90 days, work restrictions will be re-evaluated to see if reasonable accommodations can continue.
Participant's Responsibilities:
EMPLOYEE:
MANAGER/SUPERVISOR:
We have read, fully understand and agree to the duties and responsibilitiesof this modified duty assignment.
* Refusal to return to work in a modified assignment may result in reduction or suspension of your workers' compensation benefits.
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