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
□ unable to perform the physical requirements of their work or
□ is medically incapacitated: □ totally
**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
***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