Fitness For Duty (Return To Work Certification) - Montgomery County Public Schools (Page 2 of 2) in pdf

Dear Health Care Provider:

Our employee has either been on approved Family and Medical Leave Act leave, or experienced an injury or illness

not covered by FMLA that may impact their ability to safely and successfully complete their work. Please complete the

Health Care Provider certification and return the form to the Human Resources Department.

via fax to:

or via mail to:

Montgomery County Public Schools

Human Resources Department

Attn: Susan Compton

Fax: 540.394.4446

750 Imperial Street, SE

Christiansburg, VA 24073

Notice:

If the employee is returning from FMLA leave, then the employer is requesting the attached fitness-for-duty

certification only with regard to the particular health condition that caused the employee’s need for FMLA

leave on ________________________.

If you have any questions, please contact Susan Compton at 540.382.5100, ext. 1069 or email

Thank you for your assistance.

Department of Labor regulations for the Family and Medical Leave Act define a "health care provider" as: a doctor of

medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse practitioner, nurse-midwife,

or clinical social worker who is authorized to practice by the State and performing within the scope of their practice as defined

by State law, or a Christian Science practitioner. A health care provider also is any provider from whom the school system or

the employee’s group health plan will accept certification of a serious health condition to substantiate a claim for benefits.

Genetic Information Nondiscrimination Act Notice

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 fitness for duty certification. “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 and individual or family member receiving assistive reproductive services.

Fitness For Duty (Return To Work Certification) - Montgomery County Public Schools Page 2