Modified Duties Offer Letter Template
A formal template for offering modified duties to a worker recovering from an injury or illness. Designed to document restrictions, accommodations, and ensure compliance with WorkSafeBC return-to-work protocols.
This Modified Duties Offer Letter Template is used to formally document a modified work arrangement for an injured or ill employee. It outlines the restrictions, duration, accommodations, and supervisory responsibilities. When signed, it serves as a binding agreement that ensures the worker’s safe and gradual return to full duties while maintaining compliance with occupational health and safety regulations.
- Pre‑return functional capacity evaluation (FCE) or physician‑cleared restrictions must be documented before modified duties begin.
- Ensure the worker has all required PPE for the modified work environment. Additional accommodations (e.g., anti‑fatigue mat, sit‑stand stool) must be provided if needed.
- Conduct a job‑specific hazard analysis for the proposed modified duties. Identify any new hazards introduced by reduced capabilities or altered tasks.
Audit / Inspection Matrix
| Status (P/F) | Checklist Item / Hazard | Compliance Standard | Action Required / Notes |
|---|---|---|---|
| [ ] Pass [ ] Fail | Physician‑cleared work restrictions documented. | WorkSafeBC OHS Reg. 4.90 | _________________ |
| [ ] Pass [ ] Fail | Modified duties do not exceed weight/range limits. | Employer RTW policy | _________________ |
| [ ] Pass [ ] Fail | Ergonomic assessment completed for workstation. | CSA Z1004‑12 | _________________ |
| [ ] Pass [ ] Fail | Worker has received orientation on modified tasks. | OHS Reg. 3.23 | _________________ |
| [ ] Pass [ ] Fail | Emergency egress plan reviewed with worker. | NFPA 101 / OHS Reg. 2.54 | _________________ |
Incident / Corrective Action Log
| Date / Time | Item # | Safety Issue Identified | Corrective Action Taken | Assigned To |
|---|---|---|---|---|
| ___/___/_____ | _______ | _______________________________ | _______________________________ | _______ |
| ___/___/_____ | _______ | _______________________________ | _______________________________ | _______ |
By signing below, the supervisor and worker confirm that the modified duties have been reviewed, all restrictions are understood, and the environment is safe for the assigned tasks. This document becomes part of the worker’s RTW file.