Bonner County Return To Work Form Fitness For Duty Form
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1Fax, Scan or Mail to:
Bonner County
Human Resources
1500 HWY 2 #337
Return to Work Form
Sandpoint, ID 83864
HR@bonnercountyid.gov
Fitness for Duty
Fax:208-265-1456
EMPLOYEE:_________________________________________ LAST EXAM DATE: ________/_______/_________
Date of Injury/Illness/Surgery: ____________________________ NEXT EXAM DATE: _______/_______/__________
Employee’s regular job title: ______________________________ Department: _______________________________
The above-named employee is under my care. I release him/her to return to work as specified below:
FULL DUTY, usual job, no restrictions, as of: __________________________ (date.)
Transitional Work - with the following Work Restrictions/Capacities, as of __________ (date), to
be adhered to at work until their next appointment on _______________ (date).
Work FULL-TIME;
Work PART-TIME only: ______hours per day, ______ days per week
Employee can safely perform these functions: (please check below)
Lift /Carry
No restriction
Up to 5 lbs
10 lbs
25 lbs
50 lbs
Not at all
Push /Pull
No restriction
Up to 5 lbs
10 lbs
25 lbs
50 lbs
Not at all
Stand/walk
No restriction
Frequently
Occasionally
Not at all
Stoop/Bend at Waist
No restriction
Frequently
Occasionally
Not at all
Kneel/Squat
No restriction
Frequently
Occasionally
Not at all
Climb
No restriction
Frequently
Occasionally
Not at all
Sit
No restriction
Frequently
Occasionally
Not at all
Other
No restriction
Frequently
Occasionally
Not at all
Reach Above Shoulder with
Left arm/right Arm
No restriction
Frequently
Occasionally
Not at all
(circle one or both)
Repetitive use of
Left hand/ right hand
No restriction
Frequently
Occasionally
Not at all
(circle one or both)
Keyboard/mouse
No restriction
Frequently
Occasionally
Not at all
Drive
(to work / while at work
No restriction
Frequently
Occasionally
Not at all
(Circle one or both.)
Comments:_________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
OFF WORK because of Medical Necessity due to:
Hospitalization;
bed rest;
work or commute is
medically contraindicated (will worsen condition or delay recovery)
Explain (please do not include medical diagnosis): __________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Estimated date
__________________
Employee may be released:
Transitional Work
Full Duty
on date:
_______________________________________________________
HR – 11.07.14
Healthcare Provider
(Signature)
Date_______/_________/___________
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