Fitness For Duty/return To Work Certification Form printable pdf download

Human Resources

This form is to be completed by the employee’s current treating health care provider.

Fitness for Duty / Return to Work Certification

An employee coming off of leave for surgery, extended illness, injury or other medical reason must present this

Fitness for Duty Certification to Human Resources prior to returning to work.

Health Care Professionals: Your patient has three return to work options.

Review the essential duties and

physical requirement of the attached job description prior to completing this form. If the job description is not

attached, DO NOT complete.



Full Release. The patient has no work restrictions. They can return to his or her prior position

because you, the health care provider certify, that he or she can perform ALL the essential functions

and meet the physical requirements of their job without any restrictions or accommodations.



Modified Duty. The patient has some work restrictions. Work restrictions must be specifically notated

on page two of this form. Each modified duty work restriction request will be reviewed carefully to

determine if the employee can perform the essential functions of the job and return to work.

If the modified duty is temporary, list when the modified duty should end.



Not Released. The patient is not released to work in any capacity due to physical or behavioral

limitations.

GINA Provision

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 request for medical information. "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 an

individual or family member receiving assistive reproductive services.

Submission:

The Fitness for Duty / Return to Work Certification need to be submitted to the fax or email below:

To: OKCPS Human Resources

Fax: 405-587-0829

Email -

For question, contact

Mechele Berry

ph 405-587-0827

For Central Office or school site employees

Jane Pierce

ph 405-5870-814

For Central Office or school site employees

Shayna Rivera

ph 405-587-0813

For Central Office or school site employees

Anne Swan

ph 405-587-0194

For Operations based employees

OKCPS Human Resources | 900 N Klein | Oklahoma City | OK | 73106 | 405-587-0800 |

Rev1/11/17

Fitness For Duty/return To Work Certification Form

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