Employer Transitional-Permanent Job Offer {SFN 58355}

C165 EMPLOYER TRANSITIONAL / PERMANENT JOB OFFER CLAIMS DIVISION SFN 58355 (05/2019) 1600 E C entury A ve , S te 1 PO Box 5585 Bismarck ND 58506-5585 Telephone 800-777-5033 Toll Free Fax 888-786-8695 TTY (hearing impaired) 800-366-6888 Fraud and Safety Hotline 800-243-3331 www.workforcesafety.com SECTION 1 226 Injured worker222s information Claim number Injured worker222s (First name) (Last name) Employer222s name Emplo yer222s address SECTION 2 226 Job details The m edical provider has released this injured worker to return to work with the following r estrictions The job offer is Transitional Permanent Job title Dutie s include List any accommodations Return to work date Hours of work per day per week Rate of pay per hour Your medical provider has approved this position as being physically appropriate. The duties outlined above will need to be performed within your restrictions, otherwise you will need to request assistance, if needed, to perform specific tasks. Reassignment to another department might be needed if duties are not found within the medical provider222s recommendations. Notify your immediate supervisor if there are any problems in performing assigned duties. It is your responsibility to notify your supervisor if time off is requested. If working in a different department, notify the immediate supervisor of that department regarding any modifications to your work schedule. Failure to accept a modified or alternative position that is approved by a medical provider may result in termination of wage loss benefits. SECTION 3 226 Signature Return this form to your employer by indicating whether you will be returning to work. If you do not respond within the time indicated above, it means that you agree the job outlined above is appropriate, but you do not wish to accept the job and you are terminating your employment with us. I accept the position I do not accept the position Injured worker222s signature Date Employer222s signature Date American LegalNet, Inc. www.FormsWorkFlow.com