Accommodation Plan Template

Introduction:

This template is intended to assist employers in creating personalized accommodation plans for employees returning to work after an injury or illness, ensuring a supportive and effective RTW process.

Part 1: Employee Information

  • Employee Name:

  • Job Title:

  • Department:

  • Date of Injury/Illness:

  • Date of RTW Plan Creation:

Part 2: Assessment Summary

  • Nature of Injury/Illness:

  • Current Functional Capabilities:

  • Limitations/Restrictions:

  • Expected Duration of Accommodation:

Part 3: Accommodation Goals

  • Immediate Goals (e.g., facilitate initial return to work, address specific limitations):

  • Long-Term Goals (e.g., full integration into original/pre-injury role, sustained employment):

Part 4: Specific Accommodations

  • Work Schedule Adjustments:

    • Modified hours (e.g., part-time, staggered start):

    • Additional breaks/rest periods:

    • Temporary reduction in workload:

  • Physical Workspace Modifications:

    • Ergonomic equipment (e.g., chairs, keyboards):

    • Workspace relocation (e.g., closer to amenities, lower noise area):

    • Accessibility improvements (e.g., ramps, adjusted workstations):

  • Role or Task Modifications:

    • Temporary reassignment to different tasks:

    • Removal or reallocation of specific duties:

    • Modified performance expectations:

  • Technology and Equipment:

    • Assistive devices (e.g., voice-to-text software, special monitors):

    • Remote work options (if applicable):

    • Specialized tools or machinery:

Part 5: Support and Resources

  • Assigned Support Personnel (e.g., RTW coordinator, direct supervisor):

  • Training and Education (for both employee and team):

  • Health and Wellness Resources (e.g., counseling, therapy):

Part 6: Monitoring and Review

  • Initial Review Date:

  • Ongoing Review Schedule:

  • Process for Feedback and Adjustments:

Part 7: Acknowledgments

  • Employee Acknowledgment:

    • Signature:

    • Date:

  • Employer Acknowledgment:

    • Signature:

    • Date:

Conclusion:

This template aims to structure a comprehensive and individualized accommodation plan, promoting a smooth and successful return-to-work journey for the employee.