Fill and Sign the Light Duty Form

LIGHT DUTY ASSIGNMENT REQUEST FORM I hereby request that I be placed on Light Duty status. I understand that this status may be implemented on a trial basis for a period of one month. I further understand that prior to the end of the month, this employment status will be evaluated by my supervisor in conjunction with the Human Resources Department to determine if it may be continued (in increments of one month). My health provider has identified the specific restrictions I will follow (note attached). Name:       Job Title:       Date of Injury:       Employee Currently on Worker’s Compensation: Yes No A light duty assignment is not available within the department or A light duty assignment is available within the department. Briefly describe the duties:                   Start Date and Time (first day of light assignment duty):       End Date and Time (end of light assignment duty):       Employee Signature:___________________________________________________________ Date: __________ Supervisor’s Signature:_________________________________________________________ Date: __________ Human Resources Approval : Approve full length of assignment: Yes No If no, date re-evaluated: __________ Signature:____________________________________________________________________ Date: __________