Transitional Duty Offer Letter and Tracking Form

Documents a written modified-duty offer to an injured worker and tracks progress against the recovery plan to support the return-to-work program.

Submission Notice and Privacy Disclosure

• Submission Type
• Privacy and disclosure acknowledgement
• Anonymous submission
  Use only if your process allows anonymous reporting. Transitional duty offers typically require identification to support the audit trail and case tracking.

Worker and Case Identification

• Worker full name
• Employee ID
  Use only if needed for internal case matching.
• Department
• Case reference number
  Workers' compensation, incident, or claim reference number if available.
• Date of injury
  Collect only if needed to link the offer to the recovery plan.

Recovery Plan and Work Restrictions

• Current work restrictions from treating provider
  Summarize only the restrictions relevant to work assignment, such as lifting limits, standing limits, schedule limits, or prohibited tasks.
• Restriction effective date
• Expected restriction end date
• Recovery plan status
• Additional notes
  Avoid unnecessary medical detail. Use this field only for operational notes relevant to the offer.

Transitional Duty Offer Details

• Offer date
• Offer start date
• Offer end date
• Work location
• Supervisor or manager
• Modified duties summary
  Describe the transitional tasks in plain language. Do not include tasks that conflict with the documented restrictions.
• Schedule details
  Example: Monday-Friday, 8:00 AM-4:00 PM, reduced hours, or alternate schedule.

Conditional Logic and Accommodation Fit

• Does the offer fit the current restrictions?
• Mismatch details
  Explain any restriction conflicts and what needs to change before the offer can proceed.
• ADA reasonable accommodation requested?
• Accommodation details
  Capture only the functional accommodation request and the work-related impact.

Acceptance, Follow-Up, and Audit Trail

• Worker response
• Response date
• Reason for decline or delay
• Next follow-up date
• Approval status
• Approver comments