Fmla Fitness For Duty Form

FITNESS FOR DUTY FORM

EMPLOYEE:

Return completed form to employer prior to returning to work.

EMPLOYEE INFORMATION AND INFORMED CONSENT FOR DISCLOSURE OF HEALTH CARE INFORMATION

Name

Address

Telephone Number

STATEMENT OF PHYSICIAN OR PRACTITIONER

Medical Facts Regarding Patient's Condition:

Date Condition Commenced:

Probable Duration of Condition:

Has patient reached the end of his/her healing period?

Is patient able to perform all of the functions of his/her regular job?

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YES

NO

YES

NO

If essential functions were provided, please indicate any that are of concern in light of employee’s current condition.

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Is patient able to work his/her normal work schedule?

YES

NO

(If not, please identify the number of hours per day and the number of hours per week that the patient can work, and the expected duration

of the period for the reduced schedule.)

Is the patient able to return to work without posing a significant risk

When can patient return to work?

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or substantial harm to him/herself or others?

YES

NO

Restrictions?

YES

NO

If yes, describe what restrictions apply in comments.

Comments:

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of employees or their

family member. In order to comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as

defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member or an

embryo lawfully held by an individual or family member receiving assistive reproductive services.

Physician Signature

Date

PHYSICIAN OR PRACTITIONER INFORMATION

Physician Name

Address

City

State

Zip Code

Telephone

Field of Specialty

License No.

MAINTAIN THIS FORM IN FMLA CONFIDENTIAL FILE