Diagnosis & Functional Limitations Form (Dfl)

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Diagnosis & Functional
This form is confidential and
should only be faxed to: 385-646-4319
Limitations Form (DFL)
NOTE TO THE EMPLOYEE:
→
For continuing absence, additional forms must be submitted as per leave policy (every 21 calendar days: contract teacher; every 30 calendar days:
administration; every 30 calendar days: classified) or when requested by your principal, supervisor, or the Human Resources Office.
→
Doctor’s notes are not accepted. No exceptions. All fields of this form MUST be completed.
→
If filing application for short-term and/or long-term disability benefits, you acknowledge that you cannot perform the essential functions of your job with or without
reasonable accommodation.
→
Your signature on this form certifies the accuracy of the information contained herein.
→
Failure to provide this form in a proper and timely manner can result in some loss of leave benefits and/or disciplinary action.
Employee ID#:
Last Name:
First Name, MI:
Phone Number:
State:
Zip Code:
Street Address:
City:
Current Position:
Work Location:
Supervisor:
Supervisor Phone #:
I, the undersigned, authorize the release to Granite School District, of relevant medical information to
Employee’s Last Day
determine leave, benefits or return to work eligibility.
Worked is/was:
______/______/______
Employee’s Signature:
Date:
Attending Physician’s Statement:
Diagnosis
If pregnancy, est. delivery date:
Was medication prescribed?
ICD-10/ DSM-IV Diagnosis & Code Number
Probable Duration of Condition:
Days ____ Weeks____ Months____
Yes
No
Date Treated for Condition
Estimated Date Of Return
Yes
Was the patient referred to another health care provider for evaluation or treatment?
No
______/______/______
______/______/______
If yes, please provide other physician’s contact information:
,
Upon returning to work
can the employee complete the essential functions of their job?
Is this a Worker’s Comp claim?
No
Yes
No
Yes
please list any restrictions the employee may have.
Upon returning to work
,
Actual Date Released to work:
______/______/______
Physician Information
Printed Name of Attending Physician:
Area of Medical Specialty:
Phone Number:
Fax Number:
Office Hours:
State:
Zip Code:
Street Address:
City:
Physician’s Signature:
Date:
For Office Use Only
Email Supervisor
Update Spreadsheet
DFL Assigned to ____________
Date Received: ____/____/____

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