Return To Work Form printable pdf download

Return To Work Form

Medical Leave-Return to Work Form

NOTE: A portion of this form must be completed by a Health Care Provider. A copy of this Medical

Certification form must not be in a department personnel file.

PART 1: EMPLOYEE INFORMATION

Employee Name:

Dept Name:

Home Phone:

Work Phone:

Home Address:

Date Leave of Absence (or reduced schedule) Began:

Date Employee Will or Did Return to Work at Regular Schedule Hours:

Is the department requiring medical certification that the employee is fit to return to work?

Yes

If Employee is NOT returning to work enter Separation

Date :

HR Facilitator’s Signature:

Date:

Employee Signature:

Date:

PART 2: MEDICAL AUTHORIZATION

FOR MEDICAL CONDITION OF THE EMPLOYEE

List essential job duties as well as those that will be affected most directly by absences, treatment,

and recovery due to health condition: See job description attached

AUTHORIZATION: I affirm that the information regarding my medical leave request is true and accurate

to the best of my knowledge. I authorize of any medical inform to process this request

Employee Signature:

Date:

Return To Work Form