Fitness For Duty Certification printable pdf download

Fitness for Duty Certification

Form to be completed by health care provider. An employee on a medical leave under the Family and

Medical Leave Act (FMLA) must present this Fitness for Duty Certification to their supervisor prior to

returning to work.

The Family and Medical Leave Act (FMLA) guidelines are applied to employees who are on paid or

unpaid leave. This form is for return to work purposes of medical leave of absence due to an illness or

injury, whether work or non-work related. Because employees are valuable resources, health care

providers should assist employees in returning to work as soon as possible.

Health Care Professionals: Your patient has three return to work options.



Full Release. The patient has no work restrictions. They can return to his or her prior position

because you, the health care provider certify, that he or she can perform the essential functions

of their job.



Modified Duty. The patient has some work restrictions. Work restrictions must be specifically

notated on page two of this form. Each modified duty work restriction request will be reviewed

carefully to determine if the employee can perform the essential functions of the job and return

to work.



Not Released. The patient is not released to work in any capacity due to physical or behavioral

limitations.

Gina Provision

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.

Submission

The Fitness for Duty Certification can be submitted confidentially to:

Marquette University Human Resources, Attn: FMLA

PO Box 1881, Straz Tower, Room 185

Milwaukee, WI 53201-1881

Fax: (414) 288-7425 | Phone: (414) 288-7496

June 2011

Fitness For Duty Certification