Oklahoma Department Of Corrections Fmla Return To Work Medical Certification Form printable pdf download

Attachment A

OP-110218

Oklahoma Department of Corrections

FMLA Return to Work Medical Certification

Employees on FMLA leave, due to the employee’s serious illness, will not be permitted to return

to work unless their health care provider certifies that they are medically able to resume

performing essential job functions. Employees must provide this form to their health care provider

and furnish the completed form to their facility/district/unit.

The facility/district/unit must provide this form and a copy of the applicable job family descriptor to

the employee.

To be completed by the Employee:

I hereby authorize the Department of Corrections, chief administrator of Employee Services or

chief medical officer to contact the health care provider listed below to clarify or authenticate the

information below.

___________________________________________________ ________________________

Employee’s Signature

Date

To be completed by the Health Care Provider: (Please complete this form when the employee

is seeking your release to return to work)

Employee’s Name: _____________________________

SS#: __________________________

Date the condition began: _____________________

I certify that beginning __/__/__/ (date), the above named employee is able to resume performing

the functions of his/her job with or without reasonable accommodation.

If reasonable accommodation is requested, please provide the following information:

List all restriction/limitations that apply: _____________________________________________

Probable duration of restriction/limitations: ___________________________________________

Recommended accommodation(s) is/are as follows: ___________________________________

Date employee will be able to resume performing the functions of the job without restriction: ____

_________________________________________________/_______________

Health Care Provider Signature

Date

_____________________________________

________________________________

Printed Name

Type of Practice

_____________________________________

________________________________

Address

Phone

(R 11/14)

This completed form contains confidential medical information and must be maintained in the

employee’s medical file.

Oklahoma Department Of Corrections Fmla Return To Work Medical Certification Form