Sample Workplan A

This sample workplan agreement is meant to provide a basis for conversation between an employee and equitable process.


Request for Workplace Agreement for John Doe

This agreement was developed in consultation with John Doe and productivity.

To allow a successful return-to-work for John Doe, the following accommodations are requested to be provided on the first day returning to work:
  • An office in a reasonably quiet and low traffic area;
  • A team meeting in the morning that encourages all team members to:
    • Share what they have achieved in the past year;
    • Discuss projects they are currently working on;
    • Explain new processes.
  • Graduated return-to-work plan (see table below)


Start Date
April 21, 2016 2 weeks
  • 3 days/week for 4 hrs/day from 9:00 am to 1:00 pm without a lunch break.
  • Primarily computer-based training and orientation.
May 5, 2016 2 weeks
  • 3 days/week for 5 hrs/day from 9:00 am to 2:30 pm with a half hour for lunch – Monday, Wednesday and Friday.
  • Consider John’s capacity ands, John will hold discussions about additional projects as he is ready.
May 19, 2016 2 weeks
  • 4 days/week – Monday, Tuesday, Wednesday and Friday with all days except for Tuesday continuing at 9:00 am to 2:30 pm with a half hour for lunch. Tuesdays will be at 4 hours from 9:00 am to 1:00 pm without a lunch break.
  • This time frame is expected to allow John to begin work on a project or a number of projects as negotiated based on capability and complexity.
June 2, 2016 2 weeks
  • 5 days/week with Monday, Wednesday and Thursday being 4 hours per day from 9:00 a.m. to 1:00 p.m. with no lunch break.
June 16, 2016 2 weeks
  • 5 days a week with Monday, Wednesday and Thursday remaining at 4 hours per day at the hours described above.
  • At the end of the 12 weeks, the intention is that John will be back to 5 days a week and functioning at 7 hours per day.
  • It is expected and intended that John will monitor his effort at all times to maintain his well-being.
  • It is the quality of work rather than the quantity that is the objective during this time


Additional accommodations to include:
  • During the first eight weeks, John has requested to avoid meetings where the number of participants exceeds eight. In the event that John’s input is required, he will contribute in writing and review the minutes of the meeting.
  • Scheduled 10-minute weekly meetings with John’s manager will be set up to discuss John’s workplace progress and well-being. These meetings are intended to:
    • Answer the question, How is everything going? allowing John a chance to reflect on and share his experiences in the workplace over the past week.
    • Monitor commitments and deadlines; ensure that these are renegotiated as required bearing in mind that John’s perfectionist tendencies compel him to sometimes commit to unreasonable deadlines or objectives.
  • Where possible, supervisors should clearly and provide John with an opportunity to seek clarification.
  • To avoid John’s frustration with delays, it is suggested that his manager attempt to mitigate the situation by refusing unreasonable deadlines or providing sufficient support to remove the pressure associated with these.
  • Occasionally, John may need to remove himself from the work environment to take a short walk. It would be appreciated if his team could understand how John benefits from this.
John wishes to commit to the following to ensure that his return-to-work plan is successful:
  • To complete his computer-based training and all available classroom training within the first three months of his graduated return-to-work plan.
  • To resist his tendency to minimize problems so that his manager may have an accurate and how the manager may be able to help.
  • To continue his regular check-ups with medical professionals and well-being.
  • To actually take his breaks, including lunch, to ensure a more productive workday and maintain balance on a daily basis.
To assist his manager in addressing future issues, John has shared that:
  • Addressing issues immediately and directly is preferable to ‘walking on eggshells’ or letting things build into bigger issues.
  • His manager may need to closely monitor his perfectionist and over-achieving tendencies in order to ensure John’s continued well-being. Questioning his willingness to take on too much can go a long way to sustainable productivity.
  • After completion of the graduated return-to-work plan, John will be able and willing to do all required tasks. However, John’s tendency to take on too much should still be monitored.
  • John wants to continue to experience respectful and workplace issues.
  • Feedback that is specific and work-related is preferable to generalities.
The above document accurately describes my request for an effective graduated return-to-work plan.
[Signature] April 9, 2016
John Doe
Employee of Your Organization

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