REQUEST FOR TRANSITIONAL JOB OFFER CLAIMS DIVISION SFN 58355 (05/2008) Claim Number Employee Name Employer Name 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com Date Department Address Physician The physician, named above, has released you to return to work with the following restrictions: We would like you to return to work effective: Your duties will include: We have work available and the rate of pay will be Days per week, Hours per day, Your medical provider has indicated that they believe this position is physically appropriate for you at this time. The restrictions, as recommended by your physician, were reviewed and it is understood that you are to perform only duties within the guidelines and you will obtain assistance as needed for duties not within these recommendations. You understand that you may be reassigned to another department if duties are not found within the doctor's recommendations. You also understand that you are to notify your immediate supervisor if you are experiencing any problems in the performance of any duties within your restrictions, and your supervisor will contact the Safety Director. You are responsible for notifying your supervisor of any time off or modifications to your work schedule. If you are working in any other department, you will inform the immediate supervisor of that department of modifications to your work schedule. We are obligated to inform injured employees that failure to accept a modified work position that is approved by a medical provider may result in termination of wage loss benefits. Please return this form to your employer by I accept the position I do not accept the position indicating whether you will be returning to work. Employee Signature Date Safety Director Signature Date If you do not respond within the time indicated above, it means that you agree that the job outlined above is appropriate, but you do not wish to accept the job and you are terminating your employment with us. C165 American LegalNet, Inc. www.FormsWorkFlow.com