Document Sample
The following employee has been released to return to a Transitional Work Assignment (TWA) by his/her treating doctor. Employee Name: Home Department: TWA Department:
Date of Injury Released to TRTW TRTW Plan Number

Treating Doctor Name: Regular Supervisor: TWA Supervisor:
TRTW Plan Begins Plan Ends (30 days) Review Date (21days)


The treating doctor’s initial temporary work restrictions are as follows:

The Department has agreed to temporarily provide the above employee with supervised Transitional Work Assignments in accordance with the treating doctor’s restrictions. TWAs are not jobs and are temporary assignments only, intended to support expected full recovery.

Transitional Work Assignment Details
Description of Specific TWA Tasks

Schedule (days/hours)

Employee Response To Transitional Work Offer And Terms
ACCEPTANCE: Please review the roles and responsibilities section of this agreement on the back of this form.
________ (Initial) I agree to the above number of hours, schedule, and reporting location while completing Transitional Work Assignments at my usual rate of pay as outlined above. ________ (Initial) I understand the workers’ compensation system MAY NOT provide wage replacement (temporary disability) payments when a TWA is available and I fail to work the full number of hours offered by the employer. ________ (Initial) I understand that all university policies and work rules remain in effect and apply to me even though I may not be working my normal tasks or schedule. ________ (Initial) I agree to provide the doctor’s WRITTEN work status update to my supervisor after each and every visit to my treating doctor.

DECLINATION: ________ (Initial) I decline to work the offered Transitional Work Assignment, even though my action may make me ineligible for workers’ compensation lost wage replacement (temporary disability payments). I understand coverage for other workers’ compensation benefits, including medical treatment expenses, will not be affected by my decision to decline Transitional Work. I understand any use of accrued sick time will be subject to department approval and may require submitting satisfactory medical proof of inability to perform the Transitional Work Assignment. My signature below, indicates I have discussed the above transitional work assignment with my supervisor and/or the UCSC Transitional Return to Work Coordinator and understand my responsibilities while on transitional work. ______________________________________________________ ___________________________ Employee Signature Date ______________________________________________________ Supervisor Signature ______________________________________________________ Transitional Return To Work Coordinator ___________________________ Date ____________________________ Date

Please fax / send completed form to UCSC Office of Risk Services (Fax 459-3268), Mailstop: Risk Services

TRTW Agreement Form

Rev: 05/05/08

UCSC Transitional Return to Work – Roles & Responsibilities UCSC provides temporary Transitional Work Assignments for eligible employees who are temporarily unable to perform their usual and customary job duties due to work-related injury or illness. A Transitional Work Assignment is not a job but is rather a single or group of individual tasks lasting up to a total of 30 calendar days. Transitional Work Plans may be renewed and or revised up to a maximum of 90 days on a case-by-case basis. The employee and the TWA Supervisor acknowledge their responsibilities and agree to adhere to the latest medical restrictions specified by the employee’s treating doctor. Employee responsibilities while participating in transitional work program:       Follow the time and effort medical restrictions established by the treating doctor and immediately notify the TWA Supervisor if asked to perform a task that exceeds the restrictions or exceeds the employee’s abilities. Follow all attendance, work and safety rules in the TWA unit and notify TWA supervisor if unable to work for any reason Participate in medical treatment plan recommended by your physician and attend follow up medical appointments as scheduled. (Schedule medical appointments at the beginning or end of the workday if practical). Provide 3 days advance notice (where possible) to TWA Supervisor of medical/physical therapy appointments occurring during work hours, giving expected leave and return times. If taken off work completely by treating doctor, immediately notify TWA Supervisor and TRTW Coordinator (459-1787). Perform TWA duties in a professional manner. Discuss any concerns about the TWA with the TWA Supervisor or the TRTW Coordinator (459-1787).

Transitional work assignment supervisor responsibilities:    Ensure that employee is not asked or allowed to perform tasks that exceed treating doctor’s current restrictions. Limit total working hours to 40 hrs. /week or usual work schedule. With strict respect for employee confidentiality, inform the employee’s co-workers on a need-to-know basis that employee is performing a TWA with work restrictions that cannot be exceeded. Other details regarding the employee’s injury are not to be shared by the supervisor. Revise TWAs in the direction of normal duties as changes in medical restrictions allow. Consult with the TRTW Coordinator (459-1787) in the event of performance or attendance problems.

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TRTW Agreement Form

Rev: 05/05/08

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