To be completed by the employee:
I,   EMPLOYEE'S NAME   , understand the doctor's modified duty instructions and agree to follow these instructions to prevent further injury.
Modified work from   START DATE to   END DATE    :
 Fontaine Weatherproofing has temporary, modified work for you PLACE   from   START TIME  to   END TIME , Monday through Friday, with a 30-minute meal break scheduled before the 5th hour.
Restrictions:           
I {input11:shorttext-1} confirm my understanding and agreement with the above statements.
EMPLOYEE'S SIGNATURE   
To be completed by the foreman:
I,   FOREMAN'S NAME , have reviewed and understand the modified duty instructions for {input11:shorttext-1} . I acknowledge my responsibility to ensure {input11:shorttext-1} follows these instructions and provide the necessary support.   FOREMAN'S SIGNATURE   
This offer is valid until further notice. If you have concerns or questions, please contact Fontaine Weatherproofing.
Failure to comply with these instructions may result in injury and disciplinary action, including possible termination.
By signing below, we both confirm our understanding and agreement with the above statements.