Release And Return To Work - Medical Certification Form (Page 2 of 2) in pdf

Release And Return To Work - Medical Certification Form Page 2

Employee’s Ability to Work a Full Schedule – The employee is able to work (regardless of functional limitations

that may or may not apply):

⎕

A full work schedule (100%)

•

⎕*

Some but less than a full work schedule

•

⎕

None of his/her work schedule

•

*If the employee is able to work some of his/her work schedule, but less than a full schedule, please explain and

describe the extent to which the employee’s ability to work a full schedule is limited:

Employee’s Ability to Perform the Essential Functions – The Employee is able to perform:

⎕

All of the essential functions of his/her position?

•

⎕*

Some (but less than 100%) of the essential functions?

•

⎕

None of the essential functions of his/her position

•

*If the employee is able to perform some, but less than 100%, of his/her essential functions, please explain and

describe the extent to which the employee’s ability to perform the functions of his or her job is limited:

Duration:

How long will these limitations/restrictions impair the employee’s ability to perform 100% of his/her hours and

duties?

What date is the employee expected to be able to resume 100% of his/her hours and duties? _________________

PLEASE NOTE: A Medical Certification authorizing return to work WITHOUT LIMITATION (FULL RELEASE)

may be required at the time Employee is released to return to 100% of Hours and Duties.

Name of Health Care Provider (Please Print): _______________________________________________

Licensed Area of Practice or Specialty: ____________________________________________________

Address: ____________________________________________________________________________

City: _______________________________

State: ______ Zip Code: _______________________

Office Phone No: ______________________________ Tax ID Number: ________________________

Health Care Provider Signature: ________________________________ Date: ____________________

All medical/health information is maintained in a separate confidential file.

Access to this information is restricted by law to authorized persons only.

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 11/2013 (Page 2 of 2)

Release And Return To Work - Medical Certification Form Page 2