Fill and Sign the Notice of Job Assignment and Performance Requirements

NOTICE OF JOB ASSIGNMENT AND PERFORMANCE REQUIREMENTS Employee Name: ___________________________ Date: ____________ A determination of your fitness of duty has been made. You are hereby notified that, until further notice, your job assignment is:             The following features of your job assignment, or restrictions on your activities, are hereby implemented to reasonably allow you to do your work in a manner consistent with your medical condition:             The modified job assignment has been made after the Company’s determination that you can perform the job in your current condition. This determination is based upon the medical information, reports and observations, including the following:             Failure to perform the duties of this modified job will initiate a review process that may result in disciplinary action. Supervisors will monitor your attendance and job performance to ensure that the job modifications and restrictions are being utilized. Employee Comments:             ______________________________ Date: _________ Employee Signature This notice is given to employee by ___________________________ on _________ . _____________________________ ____________________________________ Supervisor Signature Employee Benefits Administrator Signature