The Formal Modified Duty Job Offer Process Toolkit - Pinnacol ...

The Job Offer Letter should be created on your company’sletterhead and include the information below.SAMPLESample Hand-Delivered Job Offer Letter (Temp Agency)1Date:Name of Employee:Employee Address:Claim #:Date of Injury:Dear (Injured worker’s name):Your treating physician has released you to modified work. We have identified a temporary position for you, which yourphysician states you will be able to perform. Please refer to the attached job task list.2The job is: See Attached. You will receive $_____ per hour.[Specify dollar amount]This modified duty job will begin at _____ on _____. Please report for work at this time and date.[3 business days from hand delivery]3Your work schedule is as follows: [Work shift as approved by treating physician]Hours/day and days/week:Report Time:Report to:Phone:Location:If the above job should no longer be available, we expect that you will contact the above stated company representative ona (daily/weekly) basis at the above location by (phone/in person) by (time) in the (morning/afternoon). This will be youronly written employment offer notification, as future offers of employment will be based on the contact procedure stateabove. If you fail to timely respond to this offer of employment, temporary benefits will be terminated.Sincerely,Employer’s SignatureEnc.: Signed copy of the Task Letter to Treating Provider dated _______________.[Task Letter must be signed and dated by the treating physician]4Certificate of Service[Employer or a representative]I _________________________________ hereby certify that I hand-delivered the above job offerto__________________________ [Injured employee’s name] [3 business day prior to start date]on ______________._________________________________________________Employer’s Signature[Must be the same person listed above]_______________Date1.800.873.7242 | www.pinnacol.com