Norristown Area School District Family & Medical Leave Forms Kit Page 13
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13RETURN TO WORK CERTIFICATION
HUMAN RESOURCES
Instructions:
1. Employee: Fill out Section 1 of this form, attach your current job description (available from the appropriate
administrator), and submit them to your health care provider.
2. Health Care Provider: Complete Sections II and III and return form to the employee of submission.
3. Employee: Submit the completed certification form to the appropriate administrator/supervisor.
I. EMPLOYEE INFORMATION
Employee Name:
Employee ID Number
Mailing Address:
Home Phone:
Principal or Supervisor
Principal or Supervisor Phone:
II. HEALTH CARE PROVIDER TO COMPLETE THE REMAINDER OF THIS FORM
Please review the attached job description.
Is the employee able to perform all the essential functions of this job? Yes No
If no, list any restrictions or describe accommodations NASD should consider:
The restrictions are: Permanent Temporary until (specify date): ___________________________
Date employee is released to return to work: _____________________________________
III. HEALTH CARE PROVIDER INFORMATION
Name of Health Care Provider:
Specialty:
Address:
Phone Number:
State License Number:
Licensed to practice in the state(s) of:
Signature:
Date:
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