Lancaster General Health Fitness For Duty Form

LANCASTER GENERAL HEALTH

FITNESS FOR DUTY FORM

(Please refer to Job Description to Complete this Form)

This form is not required if Health Care Provider would prefer to substitute their own Fitness for Duty form

provided that the GINA notification is followed in the completion of any substitute form.

GINA Safe Harbor Notification:

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered

by GINA Title II from requesting or requiring genetic information of an individual or family member of the

individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide

any genetic information when responding to this request for medical information. “Genetic information,” as

defined by GINA, includes an individual’s family medical history, the results of an individual’s or family

member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic

services, and genetic information of a fetus carried by an individual or an individual’s family member or an

embryo lawfully held by an individual or family member receiving assistive reproductive services.

Employee Name & Employee Number __________________________________________________________

may return to work in the capacity of (Job Title) __________________________________________________

effective (Date) ______________________

Employee can return to work with no restrictions.

Employee can return to work with the following restrictions:

Employee can work: ___________ hours/day _____________ days/week

Employee may drive a vehicle: Yes

Employee may lift up to ________ pounds

No lifting restrictions

Employee may stand/walk _________ hours/day

Employee may sit __________ hours/day

Employee is NOT able to: bend squat twist climb push/pull ____ pounds reach over head

Please list any additional work restrictions:

Restrictions are in effect until (Date) ___________________________

I will/will not be re‐examining this patient on (Date) _______________________________

Physician Name _______________________________________ Phone Number _______________________

(Please Print or Type)

Physician Signature __________________________________________ Date ________________________

Lancaster General Health Manager’s Initials ___________

Revised 05/13/2011

Lancaster General Health Fitness For Duty Form - 2011