Injured Worker Responsibilities Letter Template by oot20032


									       [Insert Company Name Here (Garamond 16 pt. Bold)]
                 Employee Responsibilities Letter


Injured Worker:____________________________

RE: Preparing for an Early Return to Work

Dear Injured Worker:

[Name of company] recognizes and appreciates the contributions you bring to our
organization. We wish to express our concern and support during this time of recovery from
your illness or injury. At [name of company], we are committed to facilitating your return to
productive work at your earliest opportunity. The primary goal of our Early Return to Work
Program is to provide you with duties, whenever and wherever possible, that promote
optimal safety within the specific restrictions established by your doctor.

In the event that your doctor authorizes time-off or restrictions from your regular job, you
must notify your supervisor immediately. Within the next business day, you must provide
your supervisor with a copy of the physician’s release from work or list of the restrictions.
To avoid loss of wages, it is advisable to let your doctor know that your employer provides
temporary alternate/modified work. You should request that he/she complete a Release to
Return to Work Form or work release, if appropriate. A copy of the Release to Return to
Work Form or work release should be completed and returned to your supervisor each time
you visit your doctor.

Once your doctor releases you back to your regular job, you must advise your supervisor and
be prepared to return to work at your next scheduled shift. At that time, you will be
expected to provide your supervisor with a physician-completed copy of your work release.

[Name of company] wishes you a speedy recovery and we look forward to your return. Feel
free to call [company representative] at [phone number] with any questions or concerns you
might have.


[Company Representative]

                                                                    #4 Employee Responsibilities Letter
                                                                                        OR (R 5/04)

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