Return To Work-Medical Verification Form Page 2
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2RELEASE OF MEDICAL INFORMATION
I hereby authorize Concord University to obtain and my medical provider(s) to release any medical
documentation necessary to process my request for leave or release to return to work.
Leave determinations and requests include Worker’s Compensation, Family Medical Leave Act, Parental
Leave Act, ADA, medical leave of absence without pay, use of sick leave and Catastrophic Leave. The
use of Sick or Annual Leave or any other approved leave will be determined with consideration of the
information provided by the certifying provider.
I understand Concord University may also seek medical information from me or my treatment
provider(s) in order to assess employability options including accommodation or restriction from work.
A copy of this document may be accepted the same as an original.
_____________________________________________ ______________
Employee Signature
Date
RESTRICTIONS
___________________________________ is released to return to work on_____________________
with the following restrictions:
Hours per day: 0 Normal Schedule 0 Limited Please Specify____________________
Days per week: 0 Normal Schedule 0 Limited Please Specify____________________
Restrictions during a work shift
1-3
3-5
5-8+
Bending/Stooping
0
0 hours
0
0
0
0
No restriction
hours
hours
hours
1-3
3-5
5-8+
Pulling/Pushing
0
0 hours
0
0
0
0
No restriction
hours
hours
hours
1-3
3-5
5-8+
Overhead Reaching
0
0 hours
0
0
0
0
No restriction
hours
hours
hours
1-3
3-5
5-8+
Sitting
0
0 hours
0
0
0
0
No restriction
hours
hours
hours
1-3
3-5
5-8+
Standing
0
0 hours
0
0
0
0
No restriction
hours
hours
hours
If other limitations, please specify:
Concord University PO Box 1000 Athens, WV 24712
Fax to Human Resources: (304) 384-5178
January 12, 2015
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