OFFER OF MODIFIED/LIGHT DUTY EMPLOYMENT
(Workers' Compensation Transitional Work Assignment)
SECTION 1: DOCUMENT HEADER
DATE OF OFFER: [DATE]
CLAIM NUMBER: [CLAIM NUMBER]
OFFER TYPE:
☐ Initial Modified Duty Offer
☐ Revised Modified Duty Offer (Original Date: [DATE])
☐ Extension of Modified Duty
☐ Transition from Modified to Regular Duty
RESPONSE DEADLINE: [DATE - typically 30 days from offer]
SECTION 2: EMPLOYER INFORMATION
Employer Name: [EMPLOYER LEGAL NAME]
DBA (if applicable): [DBA NAME]
Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]
Phone: [PHONE NUMBER]
Contact Person: [NAME]
Title: [TITLE]
Email: [EMAIL]
SECTION 3: EMPLOYEE INFORMATION
Employee Name: [EMPLOYEE FULL NAME]
Employee Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]
Date of Hire: [DATE]
Date of Injury: [DATE]
Regular Job Title: [REGULAR JOB TITLE]
Department: [DEPARTMENT]
Supervisor: [NAME]
SECTION 4: MODIFIED DUTY POSITION OFFER
4.1 Position Details
Modified Duty Job Title: [POSITION TITLE]
Department: [DEPARTMENT]
Work Location:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]
☐ Same location as regular position
☐ Different location (distance from regular location: [___] miles)
Supervisor: [NAME]
Supervisor Phone: [PHONE NUMBER]
4.2 Duration of Modified Duty
Start Date: [DATE]
Duration:
☐ Temporary - Estimated [___] weeks/months
☐ Until released to full duty by treating physician
☐ Until [SPECIFIC DATE]
☐ Ongoing until further notice
End Date (if known): [DATE]
4.3 Work Schedule
Days of Work:
☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday ☐ Saturday ☐ Sunday
Hours Per Day: [HOURS]
Hours Per Week: [HOURS]
Shift: [START TIME] to [END TIME]
☐ This is the same schedule as the employee's regular position
☐ This schedule differs from the regular position as follows:
[EXPLAIN DIFFERENCES]
4.4 Compensation
Wage Rate: $[AMOUNT] per [HOUR/WEEK/MONTH]
☐ Same as regular position wage
☐ Different from regular position (Regular wage: $[AMOUNT])
Benefits:
☐ All regular benefits will continue
☐ Benefits will be modified as follows: [EXPLAIN]
SECTION 5: JOB DESCRIPTION AND DUTIES
5.1 Description of Modified Duties
Primary Duties:
1. [DUTY 1]
2. [DUTY 2]
3. [DUTY 3]
4. [DUTY 4]
5. [DUTY 5]
Secondary Duties:
1. [DUTY 1]
2. [DUTY 2]
3. [DUTY 3]
5.2 Physical Requirements of Modified Position
| Physical Activity | Frequency | Duration | Weight/Force |
|---|---|---|---|
| Sitting | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | [___] hrs/day | N/A |
| Standing | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | [___] hrs/day | N/A |
| Walking | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | [___] hrs/day | N/A |
| Lifting | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | As needed | Max [___] lbs |
| Carrying | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | As needed | Max [___] lbs |
| Pushing/Pulling | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | As needed | Max [___] lbs |
| Bending/Stooping | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | As needed | N/A |
| Twisting | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | As needed | N/A |
| Reaching | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | As needed | N/A |
| Climbing | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | As needed | N/A |
| Kneeling/Squatting | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | As needed | N/A |
| Grasping/Gripping | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | As needed | N/A |
| Fine Manipulation | ☐ Never ☐ Occasional ☐ Frequent ☐ Constant | As needed | N/A |
Frequency Key: Never = 0%; Occasional = 1-33%; Frequent = 34-66%; Constant = 67-100% of workday
5.3 Work Environment
Work Setting:
☐ Indoor office environment
☐ Indoor warehouse/production environment
☐ Outdoor environment
☐ Mixed indoor/outdoor
☐ Other: [SPECIFY]
Environmental Conditions:
| Condition | Exposure Level |
|---|---|
| Extreme heat | ☐ None ☐ Occasional ☐ Frequent |
| Extreme cold | ☐ None ☐ Occasional ☐ Frequent |
| Humidity | ☐ None ☐ Occasional ☐ Frequent |
| Noise | ☐ Quiet ☐ Moderate ☐ Loud |
| Dust/Fumes | ☐ None ☐ Occasional ☐ Frequent |
| Vibration | ☐ None ☐ Occasional ☐ Frequent |
| Hazardous materials | ☐ None ☐ Occasional ☐ Frequent |
SECTION 6: MEDICAL RESTRICTIONS ACCOMMODATED
6.1 Current Medical Restrictions
Per Treating Physician's Report dated [DATE]:
| Restriction | Physician's Limitation | This Position Accommodates |
|---|---|---|
| Lifting | Max [___] lbs | ☐ Yes - Max [___] lbs |
| Standing | Max [___] hrs | ☐ Yes - Max [___] hrs |
| Walking | Max [___] hrs | ☐ Yes - Max [___] hrs |
| Sitting | Max [___] hrs | ☐ Yes - Max [___] hrs |
| Bending | ☐ Limited ☐ Avoid | ☐ Yes |
| Twisting | ☐ Limited ☐ Avoid | ☐ Yes |
| Reaching | ☐ Limited ☐ Avoid | ☐ Yes |
| [OTHER] | [RESTRICTION] | ☐ Yes |
6.2 Certification of Accommodation
This modified duty position has been designed to accommodate all current medical restrictions:
☐ Yes - All restrictions are fully accommodated
☐ Physician approval is requested for specific duties (see Section 8)
SECTION 7: EMPLOYEE RIGHTS AND NOTICES
7.1 Important Information for the Employee
Please read the following carefully:
-
Voluntary Acceptance: While you are encouraged to accept this modified duty offer, your acceptance is voluntary.
-
Impact on Benefits:
- If you accept this offer and work within your restrictions, you may receive wages instead of (or in addition to) temporary disability benefits.
- If you unreasonably refuse a bona fide offer of modified work within your restrictions, your temporary disability benefits may be reduced or terminated in accordance with state law. -
Medical Restrictions: You are expected to work only within your current medical restrictions. Do not perform any duties that exceed your restrictions. If you believe any assigned task exceeds your restrictions, notify your supervisor immediately.
-
Ongoing Medical Treatment: This offer does not affect your right to continue receiving medical treatment for your work-related injury. You may attend medical appointments during work hours with advance notice to your supervisor.
-
Right to Counsel: You have the right to consult with an attorney before responding to this offer.
-
Physician Review: You may have your treating physician review this offer to confirm it accommodates your restrictions.
7.2 State-Specific Notices
California Employees:
- Under Labor Code Section 4658.6, if you accept and perform modified work for at least 60 days, your employer may not terminate you for 90 days after completion of modified duty unless good cause exists.
- Refusal of modified work may affect your eligibility for a Supplemental Job Displacement Benefit (SJDB) voucher.
- This offer is being made within 60 days of receipt of the treating physician's report indicating you are able to return to modified work.
Texas Employees:
- Under the Texas Labor Code, if you refuse an offer of modified duty that meets your medical restrictions, your temporary income benefits may be suspended.
- You must notify the Division of Workers' Compensation if you refuse this offer.
[YOUR STATE]:
[INSERT STATE-SPECIFIC NOTICES]
SECTION 8: PHYSICIAN APPROVAL (OPTIONAL)
TO BE COMPLETED BY TREATING PHYSICIAN:
I have reviewed the modified duty position described in this offer.
☐ The described position is within the patient's current medical restrictions. I approve the patient's return to work in this position.
☐ The described position is NOT within the patient's current medical restrictions. The following modifications are needed:
____________________________________________________________________________
____________________________________________________________________________
☐ The patient is not yet ready to return to any work at this time. Anticipated return date: [DATE]
Physician Signature: _________________________________
Printed Name: [NAME], [CREDENTIALS]
Date: [DATE]
SECTION 9: EMPLOYEE RESPONSE
9.1 Employee Decision
I, [EMPLOYEE NAME], have received and reviewed this Offer of Modified/Light Duty Employment dated [DATE].
☐ I ACCEPT this offer and will report to work as follows:
- Start Date: [DATE]
- Report To: [SUPERVISOR NAME]
- Location: [ADDRESS]
- Time: [TIME]
☐ I DECLINE this offer for the following reason(s):
☐ The offered position exceeds my medical restrictions
☐ The work location is too far from my residence
☐ I am unable to work the offered hours/schedule
☐ Transportation issues
☐ Childcare/family obligations
☐ Other: [EXPLAIN]
Detailed explanation for declining:
____________________________________________________________________________
____________________________________________________________________________
☐ I REQUEST ADDITIONAL INFORMATION before making a decision:
[SPECIFY WHAT INFORMATION IS NEEDED]
9.2 Employee Certification
I understand that:
- My response to this offer may affect my workers' compensation benefits.
- I have the right to have this offer reviewed by my treating physician.
- I have the right to consult with an attorney before responding.
- If I accept, I must work within my medical restrictions and report any problems immediately.
Employee Signature: _________________________________
Printed Name: [NAME]
Date: [DATE]
Phone: [PHONE NUMBER]
SECTION 10: EMPLOYER CERTIFICATION
I certify that:
☐ This modified duty position is a bona fide position with meaningful productive work.
☐ The position described genuinely accommodates all of the employee's current medical restrictions as documented by the treating physician.
☐ The wage and benefits offered are as stated in this document.
☐ This offer is being made in good faith and in compliance with applicable workers' compensation laws.
☐ The employer will provide necessary training and supervision for this position.
☐ The employer will accommodate the employee's need to attend medical appointments related to the work injury.
Employer Representative Signature: _________________________________
Printed Name: [NAME]
Title: [TITLE]
Date: [DATE]
SECTION 11: DISTRIBUTION AND RECORD KEEPING
Send copies to:
☐ Employee (Certified Mail, Return Receipt Requested recommended)
☐ Employee's Attorney (if represented): [NAME, ADDRESS]
☐ Workers' Compensation Insurance Carrier
☐ Treating Physician
☐ Retain copy in employee personnel file
☐ Retain copy in workers' compensation claim file
Proof of Service:
Method of delivery to employee:
☐ Personal delivery - Date: [DATE]
☐ Certified mail - Date mailed: [DATE], Tracking #: [NUMBER]
☐ Email - Date sent: [DATE], Email address: [EMAIL]
☐ Other: [SPECIFY]
SECTION 12: EMPLOYER USE ONLY - TRACKING
Response Received: ☐ Yes ☐ No
Date Response Received: [DATE]
Employee's Decision: ☐ Accepted ☐ Declined ☐ No Response
If Accepted:
- Actual Start Date: [DATE]
- Position successfully maintained: ☐ Yes ☐ No
- If No, reason: [EXPLAIN]
If Declined or No Response:
- Carrier notified: ☐ Yes Date: [DATE]
- Benefits adjusted: ☐ Yes ☐ No
- Follow-up actions: [DESCRIBE]
[END OF DOCUMENT]
About This Template
Jurisdiction-Specific
This template is drafted for general use across all U.S. jurisdictions. State-specific versions with local statutory references are also available.
How It's Made
Drafted using current statutory databases and legal standards for employment hr. Each template includes proper legal citations, defined terms, and standard protective clauses.
Important Notice
This template is provided for informational purposes. It is not legal advice. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Last updated: February 2026