Ensuring that employees returning from Family and Medical Leave Act (FMLA) leave are ready to resume their duties is essential for both the employee's wellbeing and the seamless operation of the workplace. The Duty Certificate Sample form plays a crucial role in this process, acting as a bridge between healthcare providers and employers. Designed to be filled out by a medical professional, the form confirms whether an employee recovering from a serious health condition is fit to return to work, either with or without accommodations. It requests detailed information, including the employee's name, position, the nature of their health condition, the FMLA leave dates, and the treating healthcare provider's details. Moreover, it addresses the necessity for any workplace adjustments to facilitate the employee's effective reintegration. This not only supports employees in their transition back to work but also helps employers maintain a safe and productive environment. With its emphasis on confidentiality, as mandated by the Americans with Disabilities Act, the form also safeguards the employee's sensitive health information, ensuring it is handled with the utmost care and respect.
| Question | Answer |
|---|---|
| Form Name | Duty Certificate Sample Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | duty slip, duty certificate format, duty certificate format for employee, on duty certificate format |
4430.01 F4/page 1 of 1
FMLA LEAVE
(to be submitted prior to reinstatement)
Employee's Name: ____________________________________ Position: ______________________
Building: _________________________________________________
Employee's serious health condition which caused him/her to take FMLA leave:
__________________________________________________________________________________
__________________________________________________________________________________
Date FMLA leave commenced: ___________________________
Date FMLA leave is set to end: ____________________________
Name of treating health care provider: _________________________________________
Medical practice (field of specialization, if any): __________________________________
THE EMPLOYEE IS ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF HIS/HER JOB, WITH
OR WITHOUT A REASONABLE ACCOMMODATION. |
Yes No |
Any restrictions or accommodations necessary to allow the employee to return to work:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
____________________________________________________ |
_______________________ |
Health Care Provider's Signature |
Date |
The Health Care Provider Authorization for Release of Information (see Form 4430.01 F5) or a similar
THIS IS A CONFIDENTIAL RECORD AND IT SHALL BE MAINTAINED AS SUCH
AS REQUIRED BY THE AMERICANS WITH DISABILITIES ACT.
5/04
© NEOLA 2003