fitness for duty form
KKincan
4 Posts
Hello,
Does anyone have a sample "fitness for duty" form they can share?
Thank you.
Does anyone have a sample "fitness for duty" form they can share?
Thank you.
Comments
Date: 2-18-2011
Employee Name:
Date of Review:
Description of Service: Medical Surveillance Form Review,
Having reviewed the medical questionnaire form, she did not answer yes to any questions that require further intervention. She did not have any deficiencies on her tests and there are no further recommendations. XXXX Occupational Health Center examined this candidate and agrees that this person is fit to work at XXXX. A licensed medical professional did this review.
Recommendations:
None
Summary:
Fit for Duty
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If you have trouble finding it, just let me know.
Sharon
For Employee to Complete:
Name
Position
Date Leave Commenced
Anticipated RTW Date
Employee Signature/Date
For Employee's Health Care Provider to Complete:
I certify that (employee name) is able to resume work on (date). I have received and reviewed a list of the essential functions of (employee name)'s position and certify that (employee name) is able to perform those functions.
Health Care Provider Name
Address
Telephone #
Provider Signature/Date
We send this form along with a job description/essential duties description to the employee.