Fitness for Duty Certification at a glance
What it is: Fitness for Duty Certification, a form to be completed by health care provider.
Who signs: The health care provider certifies the form.
An employee on a medical leave under the Family and Medical Leave Act (FMLA) must present this Fitness for Duty Certification to their supervisor prior to returning to work.
A filled-in Fitness for Duty Certification example: a modified duty release after FMLA leave
How to fill out Fitness for Duty Certification, box by box
Employee and date of medical examination
Enter the Employee / Patient and the Date of Medical Examination.
Status of the employee's release for duty
Your patient has three return to work options: Full Release, Modified Duty and Not Released.
Full Release. The patient has no work restrictions.
Modified Duty. The patient has some work restrictions. Work restrictions must be specifically notated on page two of this form.
Not Released. The patient is not released to work in any capacity due to physical or behavioral limitations.
Please check the status of the employee's release for duty.
Check Full, unrestricted duty effective.
Check Modified duty effective and enter the date, and the next evaluation date.
Check Not released for any type of duty. Next evaluation date will be entered on its line.
Physical Evaluation
For 4. Physical Evaluation, mark Full Restrictions, Partial Restrictions (please specify) or No Restrictions.
Sedentary-Lifting 0 to 10 pounds, Light-Lifting 10 to 20 pounds, Moderate-Lifting 20 to 50 pounds, Heavy-Lifting 50 to 100 pounds, Pulling/Pushing, Carrying, "Reaching or working above shoulder", Walking, Standing, Stooping, Kneeling, Repeated Bending, Climbing, Operating a motor vehicle, Finger Manipulation (typing) and Pain (frequency, degree, signs).
Behavioral Evaluation
For 5. Behavioral Evaluation, mark Able to perform or Not Able to perform, or write Other Considerations (please specify), for Understanding, Remembering, Sustained concentration, Follow-through on instructions, Decision making, Receiving supervision and Relating to co-workers and students.
Notes, certification and provider
Write Other Restrictions, Considerations, or Notes on the lines.
By signing you certify that the facts in this document are true and correct.
Enter the Printed Name of Health Care Provider, the Date and the Phone Number.
More rules for Fitness for Duty Certification
Do not provide any genetic information when responding to this request for medical information.
If your situation is different
The employee has a medical leave of absence due to an illness or injury
This form is for return to work purposes of medical leave of absence due to an illness or injury, whether work or non-work related.
Common questions about Fitness for Duty Certification
Where do I file it?
The Fitness for Duty Certification can be submitted confidentially to: Marquette University Human Resources, Attn: FMLA PO Box 1881, Straz Tower, Room 185 Milwaukee, WI 53201-1881 Fax: (414) 288-7425 | Phone: (414) 288-7496.
Sources
[1] Fitness for Duty Certification (June 2011), the form as served (the Official source link on this page).
