"Temporary Modified-Duty Assignment for Recovering Employees" - Nevada

Temporary Modified-Duty Assignment for Recovering Employees is a legal document that was released by the Nevada Department of Administration - a government authority operating within Nevada.

Form Details:

  • Released on March 1, 2016;
  • The latest edition currently provided by the Nevada Department of Administration;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

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STATE OF NEVADA
TEMPORARY MODIFIED-DUTY ASSIGNMENT
FOR RECOVERING EMPLOYEES
Employee's Name________________________________________ Claim#_____________________________
Date of Injury_______________Date Returned to Work_______________Program End Date _____________
This assignment is available IMMEDIATELY for a maximum of 90 calendar days.
JOB AND PAY DATA
_____
Unchanged from regular work. ______Changed from regular work
_____
Full-time _____ Part Time
Shift/Days Off________________________________
Agency/Location:_______________________________________________________________________
Supervisor/(phone):_____________________________________________________________________
If part of 'Temporary Job Pool':
Regular Agency/Supervisor/Phone:____________________________________________________________
Duties Assigned/Physical requirements:
DUTIES:
% TIME/SHIFT
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
These job duties do not have the following physical requirements:
____________________________________________________________________________________________
____________________________________________________________________________________________
Supervisor Statement:
I have designed this assignment based on the treating physician's medical restrictions. If I or the employee have any
questions regarding the medical appropriateness of this assignment, I will contact the doctor immediately.
_____________________________________________________
Supervisor Signature/Date
Employee:
I have read and understand this temporary assignment. I agree to work within the restrictions listed. If I have any
questions or feel I am being asked to work beyond my capabilities, I will notify my supervisor immediately.
______________________________________________________
Employee Signature/Date
FOR OFFICIAL USE ONLY
Original to Employing Agency
Copy to Agency of Record
Copy to Employee
Copy to MCO/TPA
Copy to Risk Management if part of 'Pool of Modified Duty Jobs'
Rev. 03-16
-14-
STATE OF NEVADA
TEMPORARY MODIFIED-DUTY ASSIGNMENT
FOR RECOVERING EMPLOYEES
Employee's Name________________________________________ Claim#_____________________________
Date of Injury_______________Date Returned to Work_______________Program End Date _____________
This assignment is available IMMEDIATELY for a maximum of 90 calendar days.
JOB AND PAY DATA
_____
Unchanged from regular work. ______Changed from regular work
_____
Full-time _____ Part Time
Shift/Days Off________________________________
Agency/Location:_______________________________________________________________________
Supervisor/(phone):_____________________________________________________________________
If part of 'Temporary Job Pool':
Regular Agency/Supervisor/Phone:____________________________________________________________
Duties Assigned/Physical requirements:
DUTIES:
% TIME/SHIFT
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
These job duties do not have the following physical requirements:
____________________________________________________________________________________________
____________________________________________________________________________________________
Supervisor Statement:
I have designed this assignment based on the treating physician's medical restrictions. If I or the employee have any
questions regarding the medical appropriateness of this assignment, I will contact the doctor immediately.
_____________________________________________________
Supervisor Signature/Date
Employee:
I have read and understand this temporary assignment. I agree to work within the restrictions listed. If I have any
questions or feel I am being asked to work beyond my capabilities, I will notify my supervisor immediately.
______________________________________________________
Employee Signature/Date
FOR OFFICIAL USE ONLY
Original to Employing Agency
Copy to Agency of Record
Copy to Employee
Copy to MCO/TPA
Copy to Risk Management if part of 'Pool of Modified Duty Jobs'
Rev. 03-16
-14-