Light Duty Job Offer

Name of Medical Provider and Medical Facility:*

	Name of Medical Provider :	Name of Medical Facility:
Fill Details:

Date of the medical work status summary:*

MonthDayYear
Modified Job Role & Work Restriction
Duty Type:*

Light-Duty - Desk onlyLight-Duty - Limited MobilityLight-Duty - Mobility
Weekly Hours:*
Hourly Pay Rate:*
Medical Work Restriction:*
While you are working the light-duty job assignment, we will only assign tasks that are consistent with your physical abilities, knowledge, skills, and work restrictions as sanctioned by the medical provider. We will provide training if necessary. If you are asked to perform duties that you believe are not within your restrictions, please cease work immediately and contact your supervisor.
Please sign below either accepting or rejecting this offer and return it to our office by Date below at Local Time below. If we do not hear from you, we will assume you have rejected this offer. Rejection of this offer may affect your entitlement to or the amount of temporary income benefits.*

MonthDayYear

AM/PM Option
I Accept the Light Duty Job Offer. Employees Signature:*

Clear
I am Rejecting the Light Duty Job Offer. Employees Signature*

Clear
Date Accepted:*

MonthDayYear
Date Rejected:*

MonthDayYear
GTGS
gtgsprimelogistics@outlook.com
Should be Empty:

Light-Duty Job Offer