Monitoring/review: [Outline schedule for regular monitoring and review] Daily informal check-ins with supervisor at . Follow up review meeting with , at [date, time, location] In addition, if you (the worker), the employer, or the WSCC have any issues, difficulties, or concerns with the modified work contact [outline who to contact, how, and what you will do] Signatures: By signing this Return to Work plan we confirm our participation in the development of the plan, that we understand our roles in the implementation and monitoring of the plan, and agree to actively participate as outlined above. Supervisor/Manager: Date: Worker: Date: Union Rep (if applicable): Date:
Monitoring/review: [Outline schedule for regular monitoring and review] Daily informal check-ins with supervisor at . Follow up review meeting with , at [date, time, location] In addition, if you (the worker), the employer, or the WSCC have any issues, difficulties, or concerns with the modified work contact [outline who to contact, how, and what you will do] Signatures: By signing this Return to Work plan we confirm our participation in the development of the plan, that we understand our roles in the implementation and monitoring of the plan, and agree to actively participate as outlined above. Supervisor/Manager: Date: Worker: Date: Union Rep (if applicable): Date: