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
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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?
Offer of Modified Work Form - Custom Logo PDF Download Document and formalise the offer of modified or light duties to injured workers with a professionally designed, branded form. The Offer of Modified Work Form creates a clear written record that an employer has offered modified duties to an injured worker - a critical requirement for managing WCB and workers’ compensation claims and demonstrating due diligence under provincial OHS and workers’ compensation legislation. Each form is customised with your company logo and name, then emailed to you as a ready-to-print PDF. Upload your logo at checkout or supply your company name for text-only branding. Product Specifications: Size: 8.5" x 11" (Letter) Delivered as a print-ready PDF Custom company logo or name Ready to print and use immediately Built For: Canadian employers, HR managers, and safety supervisors managing return-to-work programs and WCB claims. Supports compliance with provincial workers’ compensation requirements and demonstrates due diligence in modified work offers across Alberta and all Canadian provinces. It is written for Canadian workplaces and formatted so it can go straight into your safety program.
Is it editable, or print-ready only?
It is supplied print-ready. If you need it adapted to your own program wording, we can do that as part of a manual build.
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.
What format is it, and when do I get it?
It is a digital download available immediately after checkout, and you can print 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.