Encl (1) to COMDTINST 12800.2
(SIC)
(DATE)
From: Name and Title of Supervisor/Manager
To:
Name of Employee
Subj: Job Offer Under the Back-To-Work Program
1. The limitations resulting from your on-the-job injury prevent you from returning to your
former job duties. Upon reviewing your condition and restrictions recommended by your
doctor, the position described below will enable you to return to work:
Job Title:
Duty Station/Location:
Pay Band/Grade:
Duty Hours:
Expected Back-To-Work Date:
If this is a change from your pre-injury average weekly wage, benefits will be adjusted.
2. The following is a brief outline of the duties assigned to the above position:
a. Describe duties and responsibilities here.
b. Any other information the employee needs to know about the position.
3. The following is an advance notice of your work schedule:
a. Monday 11/19/2001 10:00am to 3:30pm
b. Tuesday 11/20/2001 08:00am to 1:30pm
4. Please complete the bottom portion of this letter and return to this office within seven
calendar days from the date of this letter. Your worker's compensation benefit could either
be adjusted or suspended regardless of whether you accept or reject this job offer. Please be
advised that "no response" by the above date will be considered a refusal of this offer.
SIGNATURE
I ACCEPT THIS JOB OFFER
I REJECT THIS JOB OFFER
_____________________ ________
______________________ _______
Signature
Date
Signature
Date
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