Fitness For Duty (Return To Work Certification) - Montgomery County Public Schools
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1
2F
D
(R
W
C
)
ITNESS FOR
UTY
ETURN TO
ORK
ERTIFICATION
I
:
,
NSTRUCTIONS FOR EMPLOYEE
IF LEAVE PERTAINS TO YOUR OWN SERIOUS HEALTH CONDITION
THIS FORM MUST BE
.
RETURNED TO THE HUMAN RESOURCES DEPARTMENT PRIOR TO YOUR RETURN TO WORK
IF SUCH CERTIFICATION IS NOT
,
.
RECEIVED IN A TIMELY MANNER
YOUR RETURN TO WORK MAY BE DELAYED
IF LEAVE PERTAINS TO THE SERIOUS HEALTH
,
.
,
CONDITION OF A FAMILY MEMBER
THIS FORM IS NOT REQUIRED
PLEASE COMPLETE THE TOP PORTION OF THIS FORM
.
THEN FORWARD TO YOUR HEALTH CARE PROVIDER TO COMPLETE AND SIGN
THE FORM MAY BE FAXED OR MAILED BACK
MCPS HUMAN RESOURCES
540.394.4446.
TO
AT
E
Employee:
Telephone:
M
P
Employee’s Department:
Supervisor:
L
O
I authorize my health care provider to provide the following fitness for duty certification including addressing my ability to perform the
Y
essential functions of my job.:
Yes
No
E
E
Signature:
Date:
HEALTH CARE PROVIDER COMPLETES THIS SECTION
H
’
P
.
LEASE COMPLETE THE FOLLOWING INFORMATION PRIOR TO THE EMPLOYEE
S RETURN TO WORK
Printed Name of Health Care Provider:
Health Care Provider Address: _________________________
E
__________________________________________________
_________________________________________________
A
Specialty: __________________________________________
Phone Number : ____________________________________
Signature: __________________________________________
L
Fax Number:
____________________________________
Date: _____________________________________________
T
Please review the essential job duties of the employee on the attached job description. (If a job description is not attached please
contact Susan Compton at 540.382.5100, ext. 1069)
H
Is the employee able to resume work?
Yes Date of Return __________________________
No
Is the employee able to perform the essential job functions described in the attached description?
Yes
No
C
If no, please address the specific essential functions that the employee is not able to perform and include in your response whether or
A
not there is a reasonable accommodation recommended (and for how long) to enable the employee to perform these functions.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
R
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
E
___________________________________________________________________________________________________________.
Attach additional sheet(s) if needed. If the following Work Duties Restrictions form is relevant, please feel free to use it to assist you in
filling out the information regarding the essential job functions.
P
Work Duties
No
Total Restricted Hours Per Day
Hours Restricted At One Time
R
(total number of hours per day the employee
(number of hours at one time the employee
Restrictions
Restrictions
is able to work with the restrictions)
is able to work with the restrictions)
O
8+
6-8
4-6
2-4
0-2
8+
6-8
4-6
2-4
0-2
❏ Stand/Walk
❏
❏ Sit
❏
V
❏ Drive
❏
❏ Bend
❏
I
❏ Squat
❏
❏ Kneel
❏
❏ Climb
❏
D
❏ Twist
❏
❏ Crawl
❏
E
❏ Reach
❏
❏ right hand
❏
R
❏ left hand
❏
❏ overhead
❏
❏ Grasp
❏
❏ right hand
❏
❏ left hand
❏
❏ Fine Manipulation
❏
❏ right hand
❏
❏ left hand
❏
❏ Use Keyboard
❏
❏ Push/Pull
❏
❏ right hand
❏
❏ left hand
❏
❏ Lift ______ lbs
❏
❏ Carry ______ lbs
❏
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