FINANCE DEPARTMENT
Risk Management Division
- Safety
- Insurance
Date:
To:
Re:Offer of Temporary Light Duty Employment Pursuant to NRS 616C.475 (8)
Dear,
Your treating physician/medical facility has released you to light duty employment. The purpose of this communication is to document an offer of temporary light duty employment immediately available that is compatible with the physical limitations imposed by your treating physician or chiropractor.
Light duty may be performed with a modification of your current duties andat your current work location. Your work hours will be substantially similar to those worked at the time of your injury. Your gross wage will be equal to the gross wage you were earning at the time of your injury, or substantially similar to the gross wage you were earning at the time of your injury, should you be working in a different classification of employment. This position has the same employment benefits as the position you held at the time of your injury.
You remain subject to all of Washoe County’s terms and conditions of employment and are to follow procedures and policies related to your employment as you would if you were not working a light duty assignment.
Offered by:
Title:
ACKNOWLEDGEMENT BY WORKERS’ COMPENSATION CLAIMANT:
I acknowledge that my employer is providing temporary light duty employment within the physical restrictions outlined by my treating physician or chiropractor.
I understand my physical restrictions and acknowledge that I will work within those restrictions, at all times.
I acknowledge that my doctor may change my physical restrictions and this may affect the ability of Washoe County to provide a temporary light duty assignment.
I acknowledge it is my responsibility to advise the employer of my restrictions following each doctor’s visit and that my failure to do so could affect my workers compensation claim adversely and could result in disciplinary action.
I understand this offer of temporary light duty employment is not a guarantee of continued employment, nor does it constitute an employment contact. Assignments may be changed or terminated based on employer needs. The offer of temporary light duty employment may also be terminated when the treating physician or chiropractor determines I have reached maximal medical improvement, determines a change in work ability status,or determines I may return to unrestricted duty.
I understand that declining this offer of temporary light duty employment may affect my Workers’ Compensation benefits.
Please indicate below if you are accepting or declining this offer of temporary light duty employment.
ACCEPTEDDECLINED
Signed______Dated:______
Print Name:______
Oct 2012