Use this as a private worksheet
Compare the written light-duty offer with the current restrictions and actual tasks. This is not an official agency or court form.
Offer details
- ☐ Start date: ______________________________
- ☐ Hours: ______________________________
- ☐ Pay: ______________________________
- ☐ Location: ______________________________
- ☐ Supervisor: ______________________________
Task check
- ☐ Offered task: ______________________________
- ☐ Physical demand: ______________________________
- ☐ Relevant restriction: ______________________________
- ☐ Fits?: ______________________________
- ☐ Question to clarify: ______________________________
Privacy reminder
Keep sensitive medical, wage, claim-number, and employment information private. Share it only with appropriate official agencies, licensed professionals, insurers, treating providers, or other people who legitimately need it for the claim.