Summit Line Hauling, LLC

4820 Industrial Parkway, Northglenn, CO 80233
(303) 555-0190 · Return to Work Program

Confidential Case Report

Return to Work Status

Case RTW-2026-014
Report date October 21, 2026
Prepared by D. Harmon, RTW Coordinator

Confidential · Contains protected medical and claim information. Maintained separately from the personnel file and released only to persons with a documented need to know: the RTW Coordinator, the assigning supervisor, ownership, and the workers' compensation carrier.

1 Case at a Glance

Employee

Marcus D. Rivera Class A CDL Driver · hired April 17, 2023 · safety-sensitive: Yes

Current status

Transitional duty Day 17 of assignment

Next review

Oct 26, 2026 5 days out

Date of injury

Sep 29, 202622 days ago

Reported

Sep 29, 2026Same day · written notice on file

Injury

Right shoulder strainLifting / securement

OSHA recordable

YesLog 300, line 4 · job transfer case

Claim number

WC-2026-184420

Carrier

Pinnacol Assurance

Adjuster

Dana Whitfield(303) 555-0142 · d.whitfield@example.com

Injury reported

Sep 29

Medical eval

Sep 29

Work status received

Oct 2

Duty offered

Oct 3

On transitional duty

Oct 5 →

Full duty release

Pending

2 Injury and Reporting Facts

While securing a load at the customer's dock, the employee pulled a chain binder overhead with his right arm and felt immediate pain in the right shoulder. He completed the securement with assistance from the yard spotter, notified dispatch by phone within approximately fifteen minutes, and did not continue driving that day.

Location of injury	Customer dock, Meridian Building Supply, Commerce City, CO
Task at time of injury	Load securement, chain and binder
Witness	Yard spotter, Meridian Building Supply (statement obtained Sep 30)
Supervisor investigation	Completed Sep 30 by R. Castillo, Operations Supervisor. Contributing factor identified: binder length required overhead reach on a high side rail. Corrective action: cheater bars issued and overhead-reach method retrained at the Oct 8 safety meeting.
Post-accident testing	Not required. No DOT-recordable crash and no reasonable suspicion criteria met. Company post-injury testing policy: not triggered.
Near-miss history, same task	One prior near-miss reported on the same securement method, Aug 2026, same terminal.

3 Medical Status and Work Restrictions

Transcribed verbatim from the Work Status Report dated October 16, 2026, issued by Alan Reyes, MD at Northglenn Occupational Health, the authorized treating provider. No company representative modifies, interprets or summarizes these restrictions.

Work status: temporary restrictions, in effect through next evaluation
Function	Restriction	Effect on assignment
Lifting / carrying	15 lbs maximum, waist to chest only	No freight handling, no strap or chain work
Overhead reach, right arm	Prohibited	No securement, no tarping, no climbing rails
Push / pull	20 lbs maximum	Hand truck use limited to empty returns
Climbing, ladders and equipment	Prohibited	No deck or trailer-top access
Operating a commercial motor vehicle	Prohibited	Driver not dispatched; no road calls
Sitting / standing / walking	Unrestricted	Full office and yard-level work available
Medication affecting function	None prescribed as of Oct 16	No additional driving or machinery bar
Hours	8 hours per day, 5 days per week	No overtime without written approval

Next appointment	October 26, 2026, 10:15 a.m. · transportation arranged, time paid
Maximum medical improvement	Not reached. Provider estimates re-evaluation for full release at 6 to 8 weeks post-injury.
DOT medical certificate	Current, expires March 14, 2027. Provider has not voided certification; a release to drive is still required before dispatch (49 CFR 391.45).

4 Transitional Duty Assignment

Assignment

Dispatch and Compliance Support (transitional)

Reports to

R. Castillo, Operations Supervisor

Location

Northglenn terminal, dispatch office

Schedule

Monday through Friday, 8:00 a.m. to 4:30 p.m., 30-minute unpaid lunch

Rate of pay

$26.50 per hour, the employee's pre-injury hourly rate

Start date

October 5, 2026

Expected duration

Reviewed every 14 days against the current work status; not to exceed 90 days without written management approval

Assigned tasks, matched to the restriction category

Drawn from the written Light Duty Job Bank. Tasks are real work the company has on hand, not make-work.
Task	Restriction cleared	Fit
Dispatch phone coverage and driver call-backs	Sedentary, seated	Within restrictions
Driver Qualification file audit for missing documents	Sedentary, no lifting	Within restrictions
In-cab camera event review and coaching tags	Sedentary, seated	Within restrictions
Fire extinguisher, triangle and first-aid kit inventory	Lift under 15 lbs, ground level only	Within restrictions
Safety meeting material preparation	Sedentary	Within restrictions

Excluded while restrictions are in place

Operating any commercial motor vehicle · roadside work in live traffic · load securement, strapping, chaining or tarping · climbing on or under equipment · overhead work with the right arm · any task the Work Status Report prohibits. Supervisors may not assign an excluded task even at the employee's request.

Assignment log

Each transitional duty day is logged with date, hours worked, tasks performed, whether the employee reported difficulty, and the supervisor's initials. Log is current through October 20, 2026 · 12 of 12 scheduled days recorded.

5 Compliance and Documentation Check

✓Employee Injury Report signed and datedReceived Sep 29, same day as injuryComplete
✓Supervisor Injury Investigation completedR. Castillo, Sep 30, corrective action assignedComplete
✓Claim reported to the workers' compensation carrierReported Sep 30, one day after noticeComplete
✓Work Status Report obtained after each visitThree on file: Sep 29, Oct 2, Oct 16Complete
✓Transitional duty offer made in writing and signedOffered Oct 3, accepted Oct 3Complete
✓OSHA 300 log entry madeLine 4, classified as job transfer or restrictionComplete
✓Medical information filed separately from the personnel fileComplete
!Required state workers' compensation poster current and posted at the terminalPoster at the Northglenn terminal lists the prior carrier. Must be replaced.Due Oct 24 · D. Harmon
!Transitional duty assignment log signed by the supervisor weeklyWeek of Oct 12 is unsigned, entries present.Due Oct 22 · R. Castillo

Two open items

An out-of-date carrier poster and an unsigned weekly log are the two documentation gaps a defense attorney or an auditor would find first. Both are listed in Next Actions with an owner and a date.

6 Communication Log

Date	With	Method	Summary
Sep 29	Employee	Phone	Injury reported, directed to authorized provider, transportation arranged
Sep 30	Adjuster	Email	Claim filed, first report of injury and witness statement sent
Oct 2	Provider	Fax	Work Status Report received, restrictions transcribed
Oct 3	Employee	In person	Transitional duty offer reviewed and signed, copy provided
Oct 13	Employee	In person	Weekly check-in, reported no difficulty with assigned tasks
Oct 20	Employee	In person	Weekly check-in, mild soreness at end of shift, no task change requested

Program standard: the RTW Coordinator contacts the employee at least weekly while the employee is off work or on transitional duty, and documents each contact here.

7 Observations and Risk Notes

Severity	Observation
Attention	The securement method that caused this injury is still in use at two other terminals. The corrective action was delivered at the Northglenn safety meeting only.
Monitor	End-of-shift soreness reported Oct 20 without a task change. If it continues at the next check-in, send the employee back to the provider before the scheduled Oct 26 visit.
Monitor	Day 17 of a 90-day transitional duty ceiling. If no full release by the Nov 16 review, the case needs a management decision on extended accommodation.
Positive	Same-day reporting, next-day investigation and a two-day turnaround to a written offer. The early-offer pattern is what keeps the wage-loss exposure down.

8 Next Actions

Action	Owner	Due
Replace the state workers' compensation poster with the current carrier notice	D. Harmon, RTW Coordinator	Oct 24, 2026
Sign the transitional duty log for the week of Oct 12	R. Castillo, Operations Supervisor	Oct 22, 2026
Deliver the securement corrective action at the other two terminals	Safety Manager	Nov 1, 2026
Attend the provider re-evaluation and obtain an updated work status the same day	Employee / RTW Coordinator	Oct 26, 2026
Update this report and reissue to ownership and the adjuster	D. Harmon, RTW Coordinator	Oct 27, 2026

9 Review and Acknowledgment

Signing confirms the facts, restrictions and assignment recorded above are accurate as of the report date. The employee's signature acknowledges receipt of a copy and is not an agreement about the cause of the injury or the extent of the condition.

D. HarmonReturn to Work Coordinator · Date

R. CastilloOperations Supervisor · Date

Marcus D. RiveraEmployee, receipt of copy · Date

Ownership / ManagementReviewed · Date

Summit Line Hauling, LLC · Return to Work Case Report · Case RTW-2026-014 Confidential · Page 1 of 1

Summit Line Hauling, LLC

4820 Industrial Parkway, Northglenn, CO 80233
(303) 555-0190 · Return to Work Program

Letter to Employee

Transitional Duty Job Offer

Case RTW-2026-014
Claim WC-2026-184420

October 3, 2026

Marcus D. Rivera
1142 Orchard View Lane
Thornton, CO 80241

Delivered by: hand delivery, with a copy sent by certified mail

RE: Offer of transitional duty work, effective October 5, 2026

Dear Marcus,

We received the Work Status Report from Alan Reyes, MD dated October 2, 2026, which releases you to work with temporary restrictions. We have identified work that fits those restrictions, and we are offering it to you below. This offer is part of our Return to Work Program. Our goal is to keep you working, keep you paid, and keep you safe while you recover.

Position

Dispatch and Compliance Support (transitional duty)

Supervisor

R. Castillo, Operations Supervisor

Report to

Northglenn terminal, dispatch office

First day

Monday, October 5, 2026 at 8:00 a.m.

Schedule

Monday through Friday, 8:00 a.m. to 4:30 p.m., 30-minute unpaid lunch

Rate of pay

$26.50 per hour, your pre-injury hourly rate

Duration

Reviewed every 14 days against your current work status, and adjusted as your restrictions change

What you will be doing. These tasks were selected because they stay inside the restrictions on your work status:

Dispatch phone coverage and driver call-backs
Reviewing Driver Qualification files and flagging missing documents
Reviewing in-cab camera events and tagging them for coaching
Inventorying fire extinguishers, triangles and first-aid kits at ground level, nothing over 15 pounds
Preparing materials for the weekly safety meeting

What you will not be doing. You will not drive a commercial motor vehicle, work roadside, handle freight, strap, chain or tarp a load, climb on or under equipment, or reach overhead with your right arm. No supervisor may assign you any of that work while these restrictions are in place, and you should not attempt it even if you feel able.

If a task hurts. Stop the task and tell your supervisor or me the same day. We will change the assignment or send you back to the provider. You will never be disciplined for telling us that an assigned task is outside what you can do.

Your medical appointments. Keep every appointment with the authorized provider, bring us the Work Status Report from each visit on the same day, and tell us right away if your restrictions change. Appointment time during your scheduled shift is paid.

If you decline this offer. This is real work, at your regular rate, within your physician's restrictions. If you choose not to accept it, your workers' compensation wage-loss benefits may be reduced or suspended by the insurance carrier under state law. That decision belongs to the carrier, not to us. If you decline, tell us in writing on the form below so the file is complete.

Your rights. Nothing in this offer waives any right you have under the workers' compensation act or any other law. We do not retaliate against an employee for reporting an injury or filing a claim. If you believe you have been treated otherwise, contact me directly.

Please sign below and return one copy to me. Call me at (303) 555-0190, extension 112 with any question before your first day.

Thanks,

D. Harmon
Return to Work Coordinator · Summit Line Hauling, LLC

Employee response — required

I accept this transitional duty assignment. I have read the tasks and the schedule, I have a copy of this letter, and I understand I am to report any task I cannot safely perform.

I decline this transitional duty assignment. I understand my wage-loss benefits may be reduced or suspended by the insurance carrier. My reason: ___________________________________________

Employee signatureDate

Company representativeDate

Enclosures Work Status Report dated October 2, 2026 · Transitional Duty Assignment Log · Return to Work Program, employee copy

cc: personnel file (letter only) · confidential case file · Pinnacol Assurance, adjuster Dana Whitfield

Summit Line Hauling, LLC · Transitional Duty Job Offer · Case RTW-2026-014 Page 1 of 1

Summit Line Hauling, LLC

4820 Industrial Parkway, Northglenn, CO 80233
(303) 555-0190 · Return to Work Program

Letter to Employee

Return to Full Duty

Case RTW-2026-014
Claim WC-2026-184420

November 18, 2026

Marcus D. Rivera
1142 Orchard View Lane
Thornton, CO 80241

RE: Release to full duty and return to driving, effective November 20, 2026

Dear Marcus,

We received the Work Status Report from Alan Reyes, MD dated November 17, 2026 releasing you to full duty with no restrictions. Your transitional duty assignment ends at the close of business November 19, 2026, and you return to your regular position as Class A CDL Driver on November 20, 2026. Welcome back.

Before your first dispatch, we need to complete the items below. This is the same process we follow for any driver returning to safety-sensitive work, and it protects your certification as much as it protects the company.

Medical certification. Your certificate is current through March 14, 2027, and the provider has confirmed the release does not change it. A copy goes in your Driver Qualification file.
Return-to-duty review. A short sit-down with your supervisor covering the restrictions that have been lifted, the corrective action taken on the securement method, and anything you want to raise.
Equipment and route refresher. A supervised pre-trip and one accompanied run, because you have been out of the seat more than 30 days.
Drug and alcohol testing. Not required. No DOT return-to-duty test applies, as there was no prohibited-conduct violation under 49 CFR Part 382.

If symptoms return. Tell your supervisor or me the same day. Coming back to full duty does not close the door on further care, and nothing about reporting a recurrence counts against you.

Thank you for staying engaged through the transitional assignment. The dispatch and file work you did while you were out was genuinely useful to this company.

Thanks,

D. Harmon
Return to Work Coordinator · Summit Line Hauling, LLC

Return to full duty — acknowledgment

I have received this letter, completed the return-to-duty review, and I am able to perform the full duties of my position with no restrictions.

Employee signatureDate

SupervisorDate

Enclosures Work Status Report dated November 17, 2026 · Return to Full Duty Checklist

cc: Driver Qualification file (certification only) · confidential case file · Pinnacol Assurance

Summit Line Hauling, LLC · Return to Full Duty Letter · Case RTW-2026-014 Page 1 of 1

How to use this file in Lovable

The three outputs

Generation rules

Case record fields

1 Case at a Glance

2 Injury and Reporting Facts

3 Medical Status and Work Restrictions

4 Transitional Duty Assignment

Assigned tasks, matched to the restriction category

Excluded while restrictions are in place

5 Compliance and Documentation Check

6 Communication Log

7 Observations and Risk Notes

8 Next Actions

9 Review and Acknowledgment