Modified Duty Forms for Your Industry
A Stay-at-Work/Return-to-Work Program that provides modified duty helps employees return to work after an injury.
This PDF form contains form fields that allow you to indicate the tasks that are appropriate for modified duty. The form also contains open fields to enable you to enter additional tasks that you can provide for your injured worker.
Please indicate which Job Title and Industry/Department applies to the injured worker. A member of our team will review your request and provide you with the appropriate form.