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Associate Name *

First

Last

Date *

Region *

Store # *

Position *

Store Manager's Name *

Date of the Accident *

Expected date of completion *

Area (s) of Injury: *

Restrictions: *

Temporary Suitable Work *

Additional Notes: *

By signing below, I (the associate) hereby consent to the work program outlined above and I will adhere to the plan specified at all times. *

Clear Signature

Manager's Signature *

Clear Signature