Get Modified Duty Assignment Form - Capsnet Usc

This guide provides you with comprehensive instructions on how to successfully complete the Modified Duty Assignment Form - Capsnet Usc online. By following these steps, you will ensure that all necessary information is accurately filled out and submitted.

Follow the steps to complete your form efficiently.

1. Click the ‘Get Form’ button to download the form and open it for editing.
2. Begin by entering your personal details in the 'Employee' and 'Employee #' fields. Ensure that your name and identification number are correctly recorded.
3. In the 'Department' field, specify the name of the department where you work.
4. Input the 'Date of Injury,' ensuring that the date matches your medical documentation.
5. Indicate the doctor's name or the facility that provided your medical release.
6. Write the 'Date' when you received the medical release.
7. Record the medical restrictions as outlined in your release form. Make sure these are clearly stated.
8. Fill out the 'Star Date' and 'Time' fields to reflect when your modified duty assignment begins. Choose either A.M. or P.M. as applicable.
9. Specify the 'End Date' for your modified duty assignment, noting that it should not exceed 90 days.
10. Select the appropriate hours per day for your assignment, noting whether it will be full-time or part-time. If part-time, indicate the percentage of time.
11. Review the section outlining participant responsibilities and ensure you agree to the stated duties.
12. Finally, provide necessary signatures, including your own, your supervisor's, and the return-to-work coordinator's signature along with the respective dates.
13. After completing the form, save your changes. You can then download, print, or share the completed form as needed.

Begin completing your documents online today to ensure a smooth return to work.