Medical Certification - Release To Return To Work Form
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1
2st
7220 NE 181
ST
Kenmore, WA 98028
Medical Certification – Release to Return to Work Form
PH: (425) 354-1775
Fax form to: HR,
To be completed by Health Care Provider (HCP) for Non-Work Related Illness/Injury:
PLEASE PRINT LEGIBLY
(425) 354-1781
Employee Name:
Employee’s Position**:
Visit Date:
____ / _____ / ______
Hrs/shift: ____ Days/week: _____
Work schedule before leave occurred:
Check one:
___ Days
___24hr shift
Certification (to be completed by treating HCP):
The above listed employee has been examined and/or treated for a medical illness or injury that prevented them from
____ / _____ / ______ to ____ / _____ / ______
working from (date):
____/______/______ ->
Released to Full Duty (without restrictions) on:
SIGN SECTION 5 & FAX FORM TO (425) 354-1781
Released to perform modified duty, if available, from (date):
(3a) Key Objective Finding(s):
____ / _____ / ______ through ____ / _____ / ______
Describe medical facts/condition
which support restrictive release:
No restrictions to HOURS OR max HOURS per shift: _____
No restrictions to DAYS per week OR max DAYS per week: _____
: ______/______/______
Date of the next appointment or review of restrictions
Complete the Key Objective Findings Box (3a) and estimate physical capacities (Section 4)
____ / ____ / ____
___ / ____ / ___
Not released to any work from:
to
Prognosis poor for return to work in current position at any date.
May need assistance returning to work.
If employee can perform the job functions only with an accommodation, indicate what
accommodation is required in Key Objective Findings box (3a).
->
SIGN SECTION 5 & FAX FORM TO (425) 354-1781
List essential functions employee is
Temporary Restrictions
Permanent Restrictions
unable to perform and/or additional
Seldom
Constant
Employee can (related to
restrictions:
Never
Occasional
Frequent
Up to
67-100%
medical leave condition):
0% of
11-33%
34-66%
10%
No
shift
1-3 hours
3-6 hours
(Blank space = Not Restricted)
0-1 hour
restrictions
Sit
Stand / Walk
Climb (ladder, stairs, etc.)
Twist
Bend / Stoop
Squat / Kneel
Please list any additional co morbid
Crawl
conditions (including medication) that
Reach
Left, Right, Both
require consideration when returning
to work and/or impact ability to
Work above shoulders L, R, B
complete essential job functions.
Work below shoulders L, R, B
Please explain:
Keyboard
L, R, B
Wrist (flexion/extension) L, R, B
Grasp (forceful)
L, R, B
Operate foot controls
L, R, B
Vibratory tasks; high impact
Vibratory tasks; low impact
Repetitive Motion Task:
Body Part:
Rotation of Head/Neck
Psychological/Cognitive Demands:
Sensory Demands: Hear/See/Talk
Comments:
Lifting / Pushing
Never
Seldom
Occas.
Frequent
Constant
If applicable:
Example
50 lbs
20 lbs
10 lbs
0 lbs
0 lbs
Next follow-up visit:
Lift
L, R, B
_____lbs
_____lbs
_____lbs
_____lbs
_____lbs
___ / ___ / ___
Carry
L, R, B
_____lbs
_____lbs
_____lbs
_____lbs
_____lbs
Push/Pull L, R, B
_____lbs
_____lbs
_____lbs
_____lbs
_____lbs
Completed by Physician (print name): ______________________________________
Date: ____/______/________
Signature: __________________________________
Type of Practice: ____________________________________
__________________________________________________________________________
Address of Provider:
PH: (
) ________ - _____________
FAX: (
) ________ - _____________
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