(806) 687-0201


3330 70th Street, Suite 204
Lubbock, Texas 79416






By checking below and submitting the form, I acknowledge that I have received a copy of the Return-To-Work Program, and understand it is my responsibility to read the Return-To-Work Program in its entirety. I agree to comply with the rules, policies, and procedures set forth, and any revisions made to the Return-To-Work Program in the future. I also understand that if I am injured at work and I violate the rules, policies, and procedures of the Texas Administrative Code (TAC) Chapter 137, Subchapter B – Return-to-Work, that I may be subject to losing my Workers’ Compensation benefits, up to and including termination of my employment.

I understand that the Return-To-Work Program contains information about the employment policies and practices of the company. I understand that the policies outlined in this Return-To-Work Program are management guidelines only, which in a developing business will require changes from time to time. I understand that the company retains the right to make decisions involving employment as needed in order to conduct its work in a manner that is beneficial to the employees and the company. I understand that this Return-To-Work Program supersedes and replaces any and all prior Return-To-Work Programs and any inconsistent verbal or written policy statements.

I understand that the company reserves the right to revise, delete and add to this Return-To-WorkProgram at any time without further notice. I understand that no oral statements or representations can change this Return-To-Work Program. I understand that this Return-To-Work Program is not intended to create contractual obligations regarding any matters it covers and that the Return-To-Work Program does not create a contract guaranteeing I will be employed for any specific time period. I understand nothing in this program is created to infringe on any available legal rights.

If I have questions about the content or interpretation of the Return-To-Work Program, I will ask my supervisor or Human Resources.