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Associate Name
*
First
Last
Date
*
Region
*
Region 1
Region 2
Region 3
Region 4
Store #
*
Position
*
Production
Customer Service
Store Manager / Shift Manager
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
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