Light Duty Assignment Agreement

Date:

Employee Name:

Employee ID:

Department:

Supervisor:

Reason for Light Duty Assignment

Medical Provider

Physician/Provider Name:
Date of Visit:
Contact Phone:

Light Duty Work Information

Start Date:
Anticipated End Date:
Work Location:
Job Title/Duties:
Hours/Shift:
Restrictions:
Additional Comments:

Employee Agreement

  1. I acknowledge receipt and accept this Light Duty Assignment as described above.
  2. I will comply with all restrictions and report any changes in my condition to my supervisor and HR.
  3. I understand that failure to comply may result in disciplinary action.
Employee Signature:

Date:
Supervisor Signature:

Date: