Family Medical Leave Act (Fmla) And Oregon Family Leave Act (Ofla) Forms Packet, Form Cd 1422 - Employee Medical Status Report Page 6
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12OREGON DEPARTMENT OF CORRECTIONS
Employee Medical Status Report
Fax completed form to: (503) 362-2078
The Oregon Department of Corrections provides a transitional work program for short-term, medically restricted employees
who have experienced injury or illness on or off the job. This temporary transitional work program is designed to provide
transitional work, as approved by the treating physician and as appropriate for the employee’s temporary physical limitations
and/or restrictions. Transitional work is normally limited to 30 calendar days with possible extensions after review, and
typically should not extend beyond 90 calendar days. The employee is expected to adhere to the treating physician’s
restrictions. The supervisor monitors for compliance with the transitional work program.
1. Employee Name: _________________________
Date of Injury/Illness: _____________
2. Return to Work Status:
PLEASE CHECK APPROPRIATE STATUS (ONE ONLY):
May return to regular job (complete item 7 ONLY)
Date:
May return to transitional/modified duty (complete items 3 – 7)
Date:
May not return to any work (complete items 6 - 7)
Estimated date of return:___________________
3. Physical Capabilities to Perform Temporary Modified Work
Complete this section ONLY if transitional/modified duty is indicated
Capabilities
YES NO
Duration and/or Limitations
Can the patient walk?
Can the patient climb up/down stairs?
Can the patient sit?
Can the patient stand?
Can the patient use arms, wrists and
hands for fine manipulation & repetitive
movements?
Can the patient type/use a keyboard?
Can the patient lift, carry, push, pull up
to 20 pounds?
4. How many hours a DAY can the patient work?
_______________________________
5. *Inmate Contact:
None
Limited
Full
*PLEASE Note: No inmate contact may prevent patient from returning to work. Limited inmate contact
typically consists of walking past inmates but would not include direct supervision of inmates or assignment to a
response team. There is potential for inmate contact within an institution going to and from restrooms, staff dining
rooms, or locker rooms. There may also be incidental contact with inmate orderlies at any DOC facility.
6. Date of Next Appointment:
7. Physician’s Signature:
Date:
Physician’s Name (Printed): __________________________________________
Address:
Phone:
Distribution: Fax to (503) 362- 2078
CD 1422 (11/15)
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