Fitness For Duty Certification Form printable pdf download

Date: ________________

Employee Name: _______________________________________________________________________________

Employee Address: ___________________________________City/State/Zip Code: _________________________

From: Darryl Bowie, Director, Human Resources

Please take this Fitness for Duty Certification to your healthcare provider for completion. Rockdale County will use

this Fitness for Duty Certification to determine if you are able to perform the essential duties of your work.

The physician performing your exam should return the completed Fitness for Duty Certification to your Human

Resources Department. This form can be email to

or faxed to us at (770)918-6438.

FITNESS FOR DUTY CERTIFICATION

Instructions: Please complete all sections in order for the

Health Care Provider Completes this Section:

County to determine if the employee is able to return to duty. The employee’s position description or a

list of essential duties is attached to this form.

□ yes □ no

The employee is able to return to work full-time without restrictions.

If yes, list the effective date ______________________.

If no, complete the following:

The employee will be able to return to work with no limitation on (date) _____________

I certify that from (date) _____________ to (date) ____________________ the above named employee

will be:

□ unable to perform the physical requirements of their work or

□ is medically incapacitated: □ totally

□ **partially

**If partially medically incapacitated, complete the following:

Number of hours per day employee is able to work _________

Number of days per week employee is able to work _________

List any restrictions on the employee’s work:

_____________________________________________________________________________________

__________________________

__________________________________

__________________________

PRINTED Name of Health Care Provider

Type of Practice

Signature – Health Care Provider

Date

***Please return the completed form to the employee/patient****

Department of Human Resources 981 Milstead Avenue, P.O. Box 289, Conyers, GA 30012

Phone: (770)278-7575 Fax: (770)918-6438

Fitness For Duty Certification Form