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Fitness For Duty Certification

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FITNESS FOR DUTY CERTIFICATION

FACULTY/STAFF:

You are required to provide a completed fitness for duty certification prior to returning to work from your approved Family and

Medical Leave (FMLA). Once completed, the document must be submitted to Human Resources at least two business days prior

to your return to work.

This document must be completed by the health care provider who originally completed the Certification of Health Care Provider

form, thus being knowledgeable regarding your reason for using FMLA.

EMPLOYEE INFORMATION AND INFORMED CONSENT FOR DISCLOSURE OF HEALTH CARE INFORMATION

Name

BU-ID

Address

Telephone

City

State

Zip Code

PHYSICIAN OR PRACTITIONER:

STATEMENT OF PHYSICIAN OR PRACTITIONER

Date on which patient can return to work:

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

Yes

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

reduced schedule:

Describe any restrictions that may apply to the patient’s work:

Physician Signature

Date

PHYSICIAN OR PRACTITIONER INFORMATION

Physician Name

Type of Practice

Address

Telephone

City

State

Zip Code