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Modified Work Plan

Employee Name:
Date:
WCB Claim # (if applicable):
Accommodation Period:
(start date to review date)
Target End Date:

Dear (WORKER NAME HERE),

To ensure the success of your accommodation, frequent communication is required. Regardless of the
below schedule, please contact me directly and immediately if you have any concerns. The below
schedule is a minimum level of communications between us. To ensure we stay in communication with
each other, we will both agree to the below communications plan:

Who Initiates Method of Communication Frequency of Contact

 Employer Rep  On-the-job Conversation  At start/end of shift
(Name Here)  Meeting in (location here)  Once per shift
 Injured Worker  Phone Call (if not in same location)  Once per day
(Name Here) # ___________  Other (specify)
 Other: (specify) ___________
___________
Method for following Include instructions for each party if a contact time is missed.
up on a missed check-
in:

Information received from your doctor has provided us with the following restrictions:

Current Restrictions: If complex in nature, refer directly to Fitness for Modified Work
Form.

The duties and accommodations outlined below are the only duties you are authorized to engage in.
Going outside of these duties puts you at risk of re-injury or prolonging your recovery. Working outside
of these duties can result in disciplinary action.

Hours of Work: Indicate if there has been a change / reduction. If so, state the
modified hours of work.
Designated Duties: List actual duties here. Be specific and refer to Fitness for
Modified Work Form if needed.

Modified Work Plan: Injured Worker Name Here Page 1 of 2

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Additional accommodations List any special equipment or other changes required to satisfy the
required: restrictions.

These hours and duties will be in effect for the accommodation period stated at the top of this letter. In
addition to modified duties and/or hours of work, additional medical treatments may be required during
your recovery. All treatment dates/times are listed below. If additional treatments/appointment are
booked after completion of this form, you must notify me immediately.

Dates/Times of Treatment: List all treatments/appointments booked during the accommodation

period.

This agreement can be updated/changed as needed but must be signed by both parties in order for changes
to come into effect. The most current agreement is in effect until the end of the accommodation period.

Sign below to confirm your understanding and agreement to the duties and accommodations outlined
above.

Supervisor Name: Employee Name:

Supervisor Signature: Employee Signature:

Date: Date:

Modified Work Plan: Injured Worker Name Here Page 2 of 2