Transitional Duty Offer Letter and Tracking Form
Track a written transitional duty offer for an injured worker, confirm restriction fit, and log follow-up through return to work. Use it to document modified duties, ADA accommodation requests, and the audit trail in one place.
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Overview
This template documents a transitional duty offer letter and the tracking fields needed to manage a return-to-work case. It brings together the worker’s identification, the treating provider’s restrictions, the modified duties being offered, the dates involved, and the worker’s response so the record is complete and easy to review.
Use it when an injured worker can perform some work but not their full job, and you need a written offer that matches the recovery plan. The conditional logic helps you capture whether the offer fits the restrictions and, if not, why it does not fit. The accommodation fields also give you a place to note an ADA request without mixing it into the duty offer itself.
Do not use this form as a general performance document or as a place to collect broad medical history. It is not the right tool when the worker is fully released with no restrictions, when there is no modified-duty option available, or when the issue belongs entirely in a separate HR accommodation process. Keep the record focused on the offer, the response, the follow-up date, and the audit trail so the next step is clear.
Standards & compliance context
- Use data minimization under GDPR Article 5 by collecting only the worker and case details needed to document the transitional duty offer.
- If the form may be used for accommodation review, include ADA reasonable-accommodation prompts that separate the duty offer from broader medical questions.
- For health-related restrictions, follow the minimum-necessary principle by recording only the work limits needed to evaluate fit.
- Provide an audit trail for approvals, responses, and follow-up dates so the return-to-work record is defensible and easy to review.
- If the form is public-facing or worker-accessible, keep it aligned with WCAG 2.1 AA by using clear labels, validation, and accessible conditional logic.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Submission Notice and Privacy Disclosure
This section sets expectations for how the record will be used and whether the worker is submitting information directly or through a coordinator.
- 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
This section ties the offer to the correct worker, department, and injury case so the record can be found and audited later.
- 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
This section defines the medical work limits that the transitional duty offer must match, which is the basis for fit review.
-
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
This section states the actual modified assignment, dates, location, and schedule so the worker can evaluate the offer clearly.
- 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
This section captures whether the offer fits the restrictions and routes any mismatch or accommodation request into the right follow-up path.
- 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
This section records the worker’s response, the next action date, and the approval trail so the case does not stall.
- Worker response
- Response date
- Reason for decline or delay
- Next follow-up date
- Approval status
- Approver comments
How to use this template
- Enter the worker and case identification details first so the offer can be tied to the correct injury record and department.
- Record the treating provider’s restrictions, the effective date, and the expected end date before drafting the modified-duty offer.
- Describe the transitional duties, work location, schedule, and start and end dates in concrete terms that match the restrictions.
- Use the fit fields to confirm whether the offer matches the restrictions, and explain any mismatch or accommodation request with specific details.
- Capture the worker’s response, the response date, the next follow-up date, and the approver’s comments so the case has a clear audit trail.
Best practices
- Use progressive disclosure so accommodation fields only appear when the worker says the offer does not fit the restrictions or requests an accommodation.
- Keep every date in a date picker and every count or limit in a numeric field so the record is easy to validate and compare.
- Mark only the truly required fields as required, and leave optional notes optional to support data minimization.
- Write the modified duties summary in plain language that a supervisor and worker can both understand without guessing.
- Record the exact restriction mismatch instead of a vague note like "not suitable," because that makes revision faster.
- Set a follow-up date before closing the form so the return-to-work plan does not stall after the initial offer.
- If the form collects PII, include a clear consent and privacy disclosure that explains what will be stored and who can access it.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What is this template used for?
This template documents a written transitional duty offer to an injured worker and tracks the response over time. It captures the worker’s restrictions, the modified duties offered, the schedule, and whether the offer fits the recovery plan. It also creates a follow-up record so the return-to-work process is easier to review later.
Who should complete this form?
It is usually completed by a safety manager, HR representative, claims coordinator, or supervisor who is coordinating the return-to-work plan. The worker should review the offer details and record acceptance, decline, or requested accommodation. If your process requires medical review, that review should happen before the offer is finalized.
How often should this form be used?
Use it each time a new transitional duty offer is made, and update it whenever restrictions, dates, or duties change. If the worker moves from one modified assignment to another, create a new record or clearly version the existing one. The tracking fields are also useful for scheduled follow-up checkpoints.
Does this template support ADA accommodation requests?
Yes. The conditional accommodation fields let you note when the worker requests an accommodation and what was discussed. That helps separate the modified-duty offer from any broader accommodation process. Keep the form focused on what is needed to evaluate fit and next steps, not on collecting unnecessary medical detail.
What should I avoid collecting in this form?
Only collect the minimum information needed to document the offer and track the case. Avoid free-text medical history, diagnosis details, or unrelated personal data unless your process truly requires it. If you collect PII, include a clear disclosure about how it will be used and who can access it.
What happens if the offer does not fit the restrictions?
Use the mismatch fields to record the specific conflict, such as lifting limits, standing duration, or schedule issues. That creates a clear record for revising the duties, adjusting the schedule, or escalating to the next accommodation step. It also helps prevent repeated offers that do not match the provider’s restrictions.
Can this be customized for different job types?
Yes. You can tailor the modified duties summary, schedule details, and work location fields for office, field, warehouse, or clinical roles. Many teams also add conditional logic for shift work, remote tasks, light-duty equipment, or union review steps. Keep the field set narrow so the form stays usable.
How does this compare with handling return-to-work by email?
Email can confirm a decision, but it is hard to standardize, search, and audit later. This template gives you consistent fields for dates, restrictions, approvals, and follow-up, which makes the record easier to review. It also reduces missed details like response date, next check-in, or whether the offer matched the restrictions.
What systems should this connect to?
It often works best alongside incident reporting, claims management, HR case tracking, and document storage. If your workflow uses approvals, you can route the form to a supervisor or HR reviewer before the offer is sent. Linking the record to the case reference number makes it easier to find the full history later.
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