Employee Modified Duty Agreement

EMPLOYEE MODIFIED DUTY AGREEMENT

Parties and Identifying Information

Employee Name:    Employee ID:

Home Address:

Phone:    Email:

Department:    Job Title:    Supervisor:

Recitals

This Modified Duty Agreement is entered into between Employer and Employee to provide temporary modified work assignments consistent with Employee's current medical restrictions and the operational needs of the Employer. This Agreement documents the duties, schedule, compensation, duration, medical clearance requirements, and the parties' responsibilities.

Effective Dates

Modified duty shall commence on: and is expected to continue until: unless earlier terminated or extended in writing by the Employer.

Modified Duty Assignment

The Employer assigns the Employee to modified duties as described below. The Employee is required to adhere to the listed restrictions and to perform the duties in accordance with the Employer's directions.

Essential tasks not to be performed under this Agreement:

Work Schedule and Location

Work days:    Hours: From to

Location of assignment:

Compensation and Benefits

Employee's rate of pay while on modified duty:    Benefits status:

If modified duties result in lost wages beyond the scope of Employer policy, such pay adjustments shall be addressed by separate written authorization:

Medical Clearance & Monitoring

The Employee agrees to provide current written medical restrictions and periodic updates from the treating clinician. The Employer may require periodic fitness-for-duty examinations at Employer expense.

Employee must report any change in medical status immediately. No modifications to duties or restrictions will be effective without written medical documentation.

Equipment, Tools and Reasonable Accommodation

The Employee agrees to use provided accommodations and to notify the Employer if equipment is lost, damaged, or otherwise unsuitable.

Reporting, Supervision and Performance

The Employee will report to: and will follow standard reporting and timekeeping procedures. Performance of assigned duties will be evaluated and documented.

Duration, Termination and Return to Regular Duty

This Agreement is temporary and may be modified or terminated by the Employer for operational needs, noncompliance, or upon receipt of medical clearance for full duty. The Employee will be returned to regular duty upon written clearance from the treating clinician or as operationally appropriate.

Workers' Compensation and Leave

Assignment to modified duty does not constitute a determination of entitlement to benefits. Workers' compensation and other leave policies remain subject to applicable policy and law. Time worked on modified duty will be recorded in accordance with Employer policy.

Confidentiality and Records

Medical records and information related to Employee health are confidential and will be maintained separately from the personnel file in accordance with applicable privacy requirements. The Employee authorizes release of relevant medical information to the Employer for the purpose of evaluating and implementing modified duties.

Legal Notices and Statements

At-Will Employment: Nothing in this Agreement alters the at-will nature of employment unless expressly stated in a separate written agreement signed by an authorized representative of the Employer.

Equal Employment Opportunity: The Employer prohibits discrimination and provides reasonable accommodations in accordance with applicable law. Assignment to modified duty will be made without unlawful discrimination.

Employee Records for HR (required)

Dates Employed: from to

Dates Employed: from to

Education

References

Employee Acknowledgment and Certification

By signing below, I certify that all information provided on this Agreement and the attached HR records is true and complete to the best of my knowledge. I agree to perform the assigned modified duties to the best of my ability, to comply with the stated medical restrictions, and to attend any required medical evaluations.

I authorize the Employer and its agents to contact my treating clinicians and previous employers for verification of relevant medical and employment information necessary to implement this Agreement and to ensure my safe return to work.

I understand that failure to follow the terms of this Agreement, to provide requested medical documentation, or to comply with safety requirements may result in removal from modified duty and may affect my employment status or eligibility for benefits.

Employee consents to release of medical information for the limited purpose of evaluating and implementing modified duties: Yes

Acknowledgement of Receipt

Employee acknowledges receipt of this Modified Duty Agreement and understands the terms herein.

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