Company name:	Office number:

Company email:	Fax number:

Company contact person:

Questions should be directed to <COMPANY CONTACT PERSON> in the <LOCATION> office at <CONTACT NUMBER>.

Employee name: _________________________ Position title: __________________________

NOTICE TO EMPLOYEE: You are responsible for having your physician evaluate your ability to perform the essential job functions contained within your job description attached here and certify your fitness for duty by completing all items and signing below.

You must return this completed fitness for duty status and physician certification form to the appointed contact person for <COMPANY NAME AND CONTACT PERSON’S NAME> as requested. Please note that additional clarification and/or information may need to be obtained from your doctor.

To be completed by physician only: (Please refer to the attached job description) for <EMPLOYEE NAME>

Physician name (print): __________________________________________

Clinic/hospital name: ____________________________________________

Direct phone number: ________-________-____________

Is the employee able to resume work?  Yes  No

On what date is the employee able to safely return-to-work (RTW)? ____ / ____ / ______

Will employee be able to perform all essential job functions on RTW date?  Yes  No

Are there any essential job functions unable to be performed on RTW date?  Yes  No

If yes, please specify:
_____Sedentary work: lifting 10 pounds maximum. Includes occasionally lifting and/or carrying small objects. Involves sitting — a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are considered sedentary if walking, standing is required only occasionally, and all other sedentary criteria are met.
_____Light work: lifting 20 pounds maximum with frequent lifting and/or carrying objects weighing up to 10 pounds; or requires walking or standing to a significant degree; or requires sitting most of the time but includes pushing and pulling of arm and/or leg controls.
_____Light/medium work: lifting 30 pounds maximum with frequent lifting and/or carrying of objects weighing up to 15-20 pounds; or requires walking or standing to a significant degree; or requires sitting most of the time but entails pushing of arm and/or leg controls.
_____Medium work: lifting 50 pounds maximum with frequent lifting and carrying of objects.
_____Heavy work: lifting 100 pounds maximum with frequent lifting and carrying of objects weighing up to 50 pounds.
Other specific restrictions:
___climbing ___ kneeling ___ bending ___ stooping ___ repetitive motion
___ reaching ___grasping ___ overhead work ___ twisting ___ dry environment
___ other
The modified work restrictions are: ___permanent ___temporary; expected to last ____ weeks.

Anticipated date employee can be restored to full duty? ____ / ____ / ______

Are there any other restrictions/instructions the employer should be aware of?  Yes  No

If yes, please specify: medication warnings, medical device use?

Anticipated date when all restrictions can be removed? ____ / ____ / ______

Physician acknowledgement

I certify that I have examined the employee named above and declare that the statements made on this fitness for duty status and physician certification form are true and accurate. I agree to obtain the necessary approval from the employee to provide <COMPANY NAME> the information contained on this fitness for duty status and physician form and any further items needed for this certification ______________________________.
Date: ________________________.