Release And Return To Work - Medical Certification Form printable pdf download

RELEASE AND RETURN TO WORK

MEDICAL CERTIFICATION

Section 1: To be Completed by Employee

Name of Employee: ____________________________________________

CWID: _______________________________

Contact Phone Number: ____________________________________ Last Work Day Before Illness/Injury: ______________

Contact Email Address: __________________________________________________________________________________

Medical Release (completed by Patient – Employee):

I authorize my provider to release medical information necessary to process the above request or clarify

information regarding the employee’s need for leave, relief from assigned duties, or return to work, to a

representative of the District Office of Human Resources. I understand this authorization shall remain in effect for

90 days from the date of my signature.

Patient’s Signature:

Date:

Print Patient Name

Section 2: To be Completed by Medical Provider

I attended the patient for the present medical condition

from: ______________

to: ____________________

First day employee was unable to work: ___________________________________________________________

This employee is authorized to return to work on the following date: ____________________________________

The employee is authorized to return to work: (check one)

____ WITHOUT limitation(s) (full release) and resume 100% of his/her hours and duties. (Proceed to

signature section)

_____ WITH Limitation/s or Restriction/s as described on the next page. (Describe employee’s limitations or

restrictions on next page.)

Describe the employee’s physical, environment and mental limitations – as described in the employee’s job

description and work activities, or if not specifically provided, as described by the employee.

1) physical effort – for example, reading, sitting, holding, grasping, walking, talking, bending, squatting, climbing,

reaching, pulling/pushing, crawling, lifting, driving, etc.;

2) environmental conditions – for example, heights, outdoor weather conditions, temperatures, exposure to potential

hazard conditions (gases, electricity, etc.), daytime vs. night, noise, etc.; and

3) mental capabilities - for example, preparing/analyzing figures; memorizing/concentrating; learning/knowledge

retention; operate/use devices such as phone or computer; make group presentations; interact with others; self-regulate

emotion/behavior; compose information; etc.

[Use next page. Attach additional page if needed]

PLEASE RETURN COMPLETED FORM TO: Foothill-De Anza Community College District,

District Office of Human Resources, 12345 El Monte Road, Los Altos Hills, CA 94022

HR 01/2014 (Page 1 of 2)

Release And Return To Work - Medical Certification Form