Sample Workplan B

This sample workplan agreement is meant to provide a basis for conversation between an employee and an employer when there is a mutual goal of keeping the employee in the workplace as a productive, contributing member through a respectful and equitable process.


Request for Workplace Agreement for Jane Doe

This is an agreement between Jane Doe and union steward, John Smith on April 6, 2016 as a starting point for a successful return-to-work plan. This agreement does not supersede any existing company policies, collective bargaining agreements or applicable legislation. It is developed in good faith that all parties will conform to the spirit and intent of returning Jane to work in a manner that maintains a balance between health and productivity.

To allow a successful return-to-work for Jane, the following accommodations are requested:
  • A graduated return-to-work plan.
  • Jane will begin with a nine-week plan, but retain flexibility for a few additional weeks if necessary.
  • The suggested graduated return-to-work plan is as follows and will begin April 6, 2009:


Start Date
April 6, 2016 2 weeks
  • 3 hours per day, 5 days per week – 9 am to 12 pm
  • In office work only
April 20, 2016 1 week
  • 4 hours per day, 5 days per week – 9 am to 1:00 pm
  • No lunch break
April 27, 2016 1 week
  • 5 hours per day, 5 days per week – 9 am to 2:30 pm
  • ½ hour for lunch
May 4, 2016 1 week
  • 6 hours per day, 5 days per week – 8 am to 2:30 pm
  • ½ hour for lunch
May 11, 2016 1 week
  • 7 hours per day, 5 days per week – 7:30 am to 3:00 pm
  • ½ hour for lunch
May 18, 2016 Ongoing
  • 8 hours per day, 5 days per week – 7:30 am to 4:00 pm
  • ½ hour for lunch
Throughout the graduated return-to-work plan, Jane requests the following:
  • A short meeting to review and clarify expectations.
  • Assigned tasks will be given in writing on a weekly basis.
  • After the first two weeks, someone who is knowledgeable about regulations will accompany and assist Jane with her first assignments.
  • Her supervisor will be available to answer questions and update Jane on processes and procedures that have changed during Jane’s leave.
At the end of the graduated return-to-work plan:
  • After two weeks of full-time work, Jane will assume responsibility for her work plan.
  • Subject to approval by management, Jane will be given opportunities for training to improve and/or update her knowledge base.
  • Jane will continue to receive directives and instructions in writing to avoid misunderstandings.
  • Jane will continue to have regularly scheduled 10 minute check-in meetings with her supervisor to review workplace issues regarding her accommodations. Other issues can be discussed at weekly team meetings.
  • If Jane begins to cry at work, the workplace will allow her a few minutes to compose herself without worrying or reacting to it.
  • At the [formal] meeting scheduled from 10:00 am to 2:00 pm, Jane’s manager will clarify all policies and procedures especially those relating to expenses, attendance management, sick leave, and benefits.
  • Jane will clear up past expense issues.
To assist with this process, Jane has committed to:
  • Assuming the responsibility of advising her supervisor if the tasks are too little or too much for her to accomplish during the graduated return-to-work plan.
  • Doing good work.
  • Showing up on time.
  • Leaving a note on her chair and removing herself from the workplace for a few minutes to compose herself if she becomes upset.
  • Recording answers to questions around clarification of processes and procedures to reduce the time required of her supervisor to explain tasks.
  • Inputting and supplying receipts for all expenses and time sheets on a daily basis.
  • Paying all personal expenses and cell phone charges on the credit card bill.
In all work situations, new issues arise around workplace relations, performance management, and problem solving. To assist in making this ongoing process successful, Jane requests the following from her supervisor:
  • To balance positive reinforcement with necessary constructive criticism.
  • Use a solution-focused approach to performance management.
  • Refrain from speaking in anger. When either party is upset, they will wait until they are calm enough to have a civil conversation.
  • Remain respectful of all parties in all interactions.
This agreement is based on good faith and going forward with a fresh start. To succeed, all parties must agree to work towards the common goal of a successful return-to-work plan.
[Signature] April 9, 2016
Jane Doe
Employee of Your Organization

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