Date:

Employee Name:

Employee Address:

Dear

We are offering you a modified duty assignment as part of our efforts to accommodate work restrictions as advised by your treating physician. Please find the details of your assignment below.

Position Title:

Department:

Supervisor:

Start Date:

Expected End Date:

Work Schedule:

Duties and Responsibilities:

Medical Restrictions:

Compensation and Benefits:

Additional Notes:

Please review the above offer. Should you accept this temporary modified duty assignment, kindly sign below and return this letter to the Human Resources Department by the indicated deadline.

Employee Signature:

Date:

HR Representative:

Date: