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Run: 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...

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Submission Notice and Privacy Disclosure

Submission Type (required)

Privacy and disclosure acknowledgement (required)

Yes No N/A

Anonymous submission

Use only if your process allows anonymous reporting. Transitional duty offers typically require identification to support the audit trail and case tracking.

Yes No N/A

Worker and Case Identification

Worker full name (required)

Employee ID

Use only if needed for internal case matching.

Department (required)

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 (required)

Summarize only the restrictions relevant to work assignment, such as lifting limits, standing limits, schedule limits, or prohibited tasks.

Restriction effective date (required)

Expected restriction end date

Recovery plan status (required)

Additional notes

Avoid unnecessary medical detail. Use this field only for operational notes relevant to the offer.

Transitional Duty Offer Details

Offer date (required)

Offer start date (required)

Offer end date

Work location (required)

Supervisor or manager (required)

Modified duties summary (required)

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? (required)

Mismatch details (required)

Explain any restriction conflicts and what needs to change before the offer can proceed.

ADA reasonable accommodation requested? (required)

Accommodation details (required)

Capture only the functional accommodation request and the work-related impact.

Acceptance, Follow-Up, and Audit Trail

Worker response (required)

Response date

Reason for decline or delay (required)

Next follow-up date

Approval status (required)

Approver comments

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