Work Assignment Form.doc 2026

1. Click ‘Get Form’ to open the Work Assignment Form in the editor.
2. Begin by entering your name in the designated field at the top of the form. This identifies you as the employee involved in the transitional work assignment.
3. Next, fill in the 'Date of Injury' and 'Job Title' fields to provide context for your work assignment.
4. Complete the 'Department' and 'Supervisor' sections to ensure proper communication and oversight during your transitional work period.
5. Review the temporary restrictions section. Ensure that your physician's information is accurately recorded, including their name and date of notification regarding your restrictions.
6. In the 'Temporary Work Assignments' section, indicate your expected return date and time, along with your scheduled hours per day and week.
7. List any initial work activities assigned to you, ensuring they align with your physical abilities as outlined by your physician.
8. Finally, sign and date where indicated to confirm your consent or refusal of the transitional work assignment. Make sure both you and the TWP Coordinator sign off on this document.

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