Get Modified Duty Form - Winnipeg Regional Health Authority

Completing the Modified Duty Form is an essential step for individuals returning to work after an illness or injury. This guide provides a clear, step-by-step approach to filling out the form online, ensuring that users can navigate the process with ease and confidence.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the Modified Duty Form and open it in your preferred editor.
2. Begin by entering the name of the employee and their position in the designated fields. Clearly state the nature of the illness or injury, but remember to avoid providing specific diagnoses.
3. Indicate whether the employee is returning to regular duties or modified duties. If modified duties are required, specify if the return is temporary or permanent.
4. Fill in the start date for the modified duties and provide an estimated duration. Also, confirm whether objective evidence has been confirmed by selecting 'Yes' or 'No'.
5. Complete the graduated return proposal by indicating the number of hours per day the employee will be working and assess if returning to work is not appropriate at this time, along with providing objective reasoning if applicable.
6. Evaluate the employee's work abilities in the physical demands section. Indicate capability levels for tasks such as lifting, carrying, and pushing/pulling, with specific details for each category.
7. Assess psychosocial demands that may impact work duties. Provide comments on factors like multi-tasking, work under pressure, or meeting deadlines.
8. Enter the date of examination and the date of the next appointment, followed by the health care provider's printed name, address, signature, and phone number.
9. Authorize the release of information to the Winnipeg Regional Health Authority by signing where indicated, ensuring all provided information is accurate before final submission.
10. Once you have filled out all relevant sections, save the changes, and download the completed form. You may choose to print or share it as necessary.

Complete your Modified Duty Form online today to ensure a smooth and efficient return to work.