1.

Light Duty/Transitional Job

* Employer Name:

* Phone #:

* Title:

Company

* Worker Name:

Claim #:

* Date:

2.

Essential task description:

* Location

Choose one

Office Yard/Warehouse Job Site

* Hours per day:

* Days a week/shift:

A service of

In cooperation with

Funding and support for the SMART / MBA Return to Work grant has been provided by the State of Washington, Department of Labor and Industries, Safety and Health Investments Project.