Safety Forms
Offer of Modified Work Form
An Offer of Modified Work form that formalizes a modified or light-duty placement for an injured worker - position, specific duties, hours, length of placement, rate of pay, and a supervisor to report to - delivered as a real fillable PDF, not a verbal offer with no paper trail.
- Fillable PDF — type into it on any device, or print it blank
- Single page, 8.5" x 11" (Letter)
- Add your company logo at checkout — no extra charge
- Written by Canadian safety professionals to provincial OHS standards
- Instant download after purchase
Written by certified COR auditors · Trusted by Canadian contractors for 17+ years · Secure Stripe checkout · Instant delivery + re-download any time from your purchases page
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THE POSITION, THE DUTIES, THE HOURS, AND THE PAY RATE, SPELLED OUT IN WRITING BEFORE THE WORKER SIGNS
What you get
- A fillable PDF - type directly into every blank, including the fields worked into the letter's own sentences
- Employee Name and Case Number fields, plus the Modified Position and a 4-line Duties description
- Hours of work (start/end time) and length of placement (start/end date) fields
- A rate of pay field, a named supervisor, and a Case Coordinator meeting name
- Offer Accepted / Offer Rejected checkboxes with a date field for each outcome
- Supervisor Signature and Case Coordinator fields
- Your company logo added to the form, at no extra charge
How to fill it out and keep it. Open it in Adobe Acrobat Reader (free) or a desktop browser like Chrome or Edge, then use that program's own Save or Download button, not just closing the tab, so your entries are kept in the saved copy. On a phone, most PDF apps will let you view the form but not type into it - fill it out on a computer, or print it and use a pen.
Specifications
- Size
- 8.5" x 11" (Letter)
- Format
- Fillable PDF - type into it on any device, or print it blank
- Company logo
- Included - upload at checkout, or we print your company name instead
- Delivery
- Instant download after purchase
Why crews use it
- Spelling out the specific duties, hours, and rate of pay in writing means there's no ambiguity later about what was actually offered versus what the worker remembers being told
- An Offer Accepted / Offer Rejected checkbox with a date creates a clear, dated record of the worker's response - critical if a WCB claim is later disputed
- Naming both a supervisor and a Case Coordinator on the same document establishes who the worker reports to and who reviews the placement, avoiding confusion during the modified work period
- A written offer is exactly the kind of due-diligence evidence WCB expects when an employer claims to have accommodated an injured worker
Built for
- HR managers and safety supervisors managing return-to-work programs for injured workers
- Employers documenting modified or light-duty work offers as part of a WCB claims management process
- Case coordinators and supervisors overseeing a worker's progress through a modified work placement
Why it matters
A verbal offer of modified work leaves an employer with nothing to show if a WCB claim is disputed or a worker's recollection of the offer doesn't match what was actually proposed. A signed, dated written offer - with the duties, hours, and pay rate spelled out - is what demonstrates due diligence under provincial workers' compensation legislation and protects both the worker and the employer.
Try it right here
Click a box. Type a line. See how it feels before you buy.
This is the real form layout - what you type here isn't saved or sent anywhere, it's just so you can see the fields work before you pay.
Common questions
Before you buy
What people ask us about the Offer of Modified Work Form.
What is the Offer of Modified Work Form used for?
An Offer of Modified Work form that formalizes a modified or light-duty placement for an injured worker - position, specific duties, hours, length of placement, rate of pay, and a supervisor to report to - delivered as a real fillable PDF, not a verbal offer with no paper trail. Who uses it: HR managers and safety supervisors managing return-to-work programs for injured workers; Employers documenting modified or light-duty work offers as part of a WCB claims management process; Case coordinators and supervisors overseeing a worker's progress through a modified work placement.
Can we fill it in on a computer, or is it print-only?
Both. It is a fillable PDF, so every field can be typed into on a laptop or tablet and saved, or you can print it blank and fill it in by hand. Your company logo is added at no extra charge.
Does using this form make us compliant?
No single form makes a company compliant. A form is the evidence half of a safety program - it records that something was checked and by whom. It carries weight at audit time when the written program behind it says the check is required and how often. If that program does not exist yet, that is the part we write.
When do I get it?
Immediately after checkout as a download, and you can re-download it any time from your purchases page. Print or fill in as many copies as your own crews need.
From the team that wrote it
These forms come from a bigger program.
Inspection and competency forms are the evidence half of a safety program. If the program they belong to does not exist yet, or has not been updated in a few years, that is the part we write.