Get Premade Modified Duty Form

The Premade Modified Duty Form is essential for documenting job modifications available for employees recovering from an injury. This guide will provide you with clear, step-by-step instructions to complete the form online effectively.

Follow the steps to complete your Premade Modified Duty Form online:

1. Locate the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering the date at the top of the form. This date should reflect when the report is completed.
3. Fill in the employer's name in the provided section to identify who is completing the form.
4. Enter the employee's name to specify whose modified duty availability is being reported.
5. Indicate whether modified duty is available by checking ‘Yes’ or ‘No’ and fill in the period of availability if applicable.
6. Specify the job title for the modified duty role that you are reporting.
7. Provide a detailed job description, including any specific duties and responsibilities associated with the role.
8. Describe the environment and working conditions associated with the job. This includes factors like temperature and physical workspace.
9. In the additional information section, indicate the hours per day that the job is available by circling the minimum and maximum options.
10. Fill out the maximum required hours for various work postures by circling the appropriate numbers for sitting, standing, walking, and driving.
11. Choose the relevant lift/carry and push/pull classifications by checking the appropriate options based on the job requirements.
12. Complete the section that assesses required physical activities (e.g., bending, climbing) by circling the percentage that applies to the job.
13. In the employer section, document the date the job is available and add any further comments as needed.
14. Have the employer sign and date the form to authorize the information provided.
15. Send the form to the physician for approval. They will need to indicate their approval status and may provide additional modifications.
16. Ensure the physician signs the document, prints their name, and includes their certification number if applicable.
17. After completing the form, save your changes. You can then download, print, or share the completed form as needed.

Start completing your Premade Modified Duty Form online today!