Return To Work Certification For Family And Medical Leave (Fml)
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RETURN TO WORK CERTIFICATION
For Family and Medical Leave (FML)
SECTION I – To be completed by THE EMPLOYER
EMPLOYEE'S NAME (LAST, FIRST, MIDDLE INITIAL)
EMPLOYEE'S DEPARTMENT
DEPARTMENT CONTACT
DEPARTMENT CONTACT'S MAILING ADDRESS
PHONE
FAX
E-MAIL
SECTION II – To be completed by HEALTH CARE PROVIDER
NAME OF HEALTH CARE PROVIDER
ADDRESS
PLACE ADDRESS STAMP HERE:
PLEASE COMPLETE THE FOLLOWING AND RETURN THE FORM TO THE EMPLOYEE
OR TO THE DEPARMENT CONTACT LISTED ABOVE PRIOR TO THE RETURN TO WORK DATE
Important: Please limit your answers below to the serious health condition for which the Employee
has been on leave.
THE GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008 (GINA): 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 an individual or family member of the individual, except as
specifically allowed by this law. 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 sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an
individual or family member receiving assistive reproductive services.
1. Is the employee now able to perform those essential functions of his or her job that she could not previously
perform because of the serious health condition for which the employee has been on leave?
No.
Yes.
Yes, with restrictions
[indicate date]
2. Employee released to return to work effective:
____________________
3. If the Employee is released to work but is restricted in his or her ability to perform the essential functions of
his or her job as a result of the serious health condition for which the employee has been on leave, please
describe those restrictions:
4. The foregoing restrictions are:
Permanent
Temporary, until:
____________________
[indicate date]
SIGNATURE
SIGNATURE OF HEALTH CARE PROVIDER
DATE
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