Huntington Fitness-For-Duty Certification printable pdf download

Huntington Fitness-For-Duty Certification

(To be completed by the

ealth Care Provider)

Employee Name: __________________________________________________________

Social Security Number: ________-______-________

The employee listed above can return to work on: _____/______/_____

I certify that the employee may return to work with no restrictions

I certify that the employee may return to work with the following restrictions:

________________________________________________________________________

These restrictions will remain in effect for the following period (duration):

________________________________________________________________________

(This certification relates only to the particular health condition that caused the leave.)

Signature of Health Care Provider: ____________________________________________

Type of Practice: __________________________________________________________

Address: _________________________________________________________________

_________________________________________________________________________

Telephone Number: (______) ____________________________________

Fax Number: (______) _________________________________

You will not be allowed to return to work until you have provided a Fitness-for-Duty certification

to your manager. Managers, please submit this Fitness for Duty certification to:

Leave Administration – HP0600

Huntington National Bank

37 W Broad Street, Columbus, OH 43215

Fax #: 877-219-2224

Posted January 2017

Huntington Fitness-For-Duty Certification