Date:_____________________

This agreement is executed in connection with the undersigned licensed nurse's participation in the _____________________________(Employer) Program for Impaired Nurses. It is the purpose of this Agreement to prevent any misunderstanding as to the terms and time specified. This agreement is specifically designed to meet the needs of the facility and the individual and is uniquely adapted to the recovering individual.

I, ____________________________(Nurse), enter into this agreement on the above date with ___________________________(Employer) and the ____________________________ (Treatment Program).

In consideration of my being permitted to continue in, or to return to, the employ of ___________ ________________(Employer), I agree to the Terms and Conditions set out in this Agreement. I understand that the Employer agrees to employ me only on these terms and conditions and that failure to comply with the terms of this Agreement shall be grounds for either additional disciplinary action or possible termination.

The Terms and Conditions on this Agreement shall remain in force for a period of two (2) years from the above date but are subject to modification if the Employer, in consultation with treatment provider, decides such modification is in the best interest of the Nurse's rehabilitation or necessary to protect the health and safety of clients/patients. I understand and agree that this Agreement does not obligate the Employer to employ me for a two (2) year period and that, except as provided in the Agreement, I am employed on the same terms and conditions as the Employer's other employees.

This Agreement consists of this page plus the attached Terms and Conditions for Return to Work, each page of which is initialed by the undersigned parties.

Any modification of the printed terms of the Agreement must be approved by ___________________________ (Employer), the undersigned nurse and, if applicable, collective bargaining representative.

Executed on the date shown above.