Fitness For Duty Template PDF Details

The Fitness for Duty Template is a new online tool designed to help law enforcement agencies screen and evaluate the physical condition of their officers. Developed by the National Institute of Justice, the template is a simple questionnaire that assesses an officer's functional ability in six areas: musculoskeletal, respiratory, cardiovascular, neurologic, gastrointestinal, and endocrine. Agencies can use the results of this assessment to identify officers who may be at risk for injury or illness and provide them with appropriate interventions. The Fitness for Duty Template is available free of charge on the NIJ website.

This table contains information regarding fitness for duty template. You will have the rough time you'll need to fill in the form and a few other details.

Form NameFitness For Duty Template
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesfitness for duty certification form, fitness for duty form shrm, fitness for duty certification, unum fitness for duty form

Form Preview Example

Fitness for Duty Certification

Form to be completed by health care provider. 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.

The Family and Medical Leave Act (FMLA) guidelines are applied to employees who are on paid or unpaid leave. 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. Because employees are valuable resources, health care providers should assist employees in returning to work as soon as possible.

Health Care Professionals: Your patient has three return to work options.

Full Release. The patient has no work restrictions. They can return to his or her prior position because you, the health care provider certify, that he or she can perform the essential functions of their job.

Modified Duty. The patient has some work restrictions. Work restrictions must be specifically notated on page two of this form. Each modified duty work restriction request will be reviewed carefully to determine if the employee can perform the essential functions of the job and return to work.

Not Released. The patient is not released to work in any capacity due to physical or behavioral limitations.

Gina Provision

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic Information" as defined by GINA includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.


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

June 2011

Fitness for Duty Certification


Employee / Patient



Date of Medical Examination


3.Please check the status of the employee’s release for duty

Full, unrestricted duty effective __________________________

Modified duty effective ________________ and next evaluation date ________________

Not released for any type of duty. Next evaluation date will be ________________

4. Physical Evaluation


Partial Restrictions

No Restrictions


(please specify)


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





Repeated Bending


Operating a motor vehicle

Finger Manipulation (typing)

Pain (frequency, degree, signs)

5. Behavioral Evaluation

Able to

Other Considerations

Not Able to


(please specify)




Sustained concentration

Follow-through on instructions

Decision making

Receiving supervision

Relating to co-workers and students

6.Other Restrictions, Considerations, or Notes



I hereby certify that the facts in this document are true and correct.




Printed Name of Health Care Provider


Phone Number



June 2011

How to Edit Fitness For Duty Template Online for Free

There's nothing complex related to filling out the fit for duty form template when you use our PDF editor. By following these easy steps, you will definitely get the fully filled out PDF within the least time frame possible.

Step 1: Select the "Get Form Now" button to get going.

Step 2: The document editing page is presently available. Include text or change present data.

The following segments will make up the PDF template that you'll be completing:

portion of spaces in fitness for duty template

Provide the necessary data in the SedentaryLifting to pounds, Behavioral Evaluation, Understanding Remembering, Able to perform, Other Considerations please specify, Not Able to perform, and Other Restrictions Considerations area.

Filling out fitness for duty template stage 2

In the area dealing with I hereby certify that the facts in, Printed Name of Health Care, Date, Phone Number, and June, you have to note down some essential information.

Completing fitness for duty template part 3

Step 3: Select the "Done" button. Finally, you can export the PDF document - download it to your device or deliver it by means of email.

Step 4: Try to make as many duplicates of the form as possible to keep away from potential issues.

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