Return Work Medical Certification – Fill Out and Use This PDF

Return Work Medical Certification is a popular choice among employees with back pain because it reduces the risk of injury, which can pay off in the long run.

If you need to obtain this form PDF, our document tool is the thing you need! By clicking on the orange button below, you will access the page where you can modify, save, and print your PDF file. Benefit from the simplicity of navigation and user interface the editor presents.

Get Form Now Download PDF

Return Work Medical Certification first page preview

Return Work Medical Certification PDF Details

If you have recently returned to work from an illness or injury, your employer may ask you to complete a return work medical certification form. This form is used by your employer to determine if you are able to return to work and what restrictions, if any, should be placed on your job duties. Completing the form accurately is very important, as it can help ensure that you are able to get back to work as soon as possible. If you have any questions about how to complete the return work medical certification form, be sure to talk with your doctor or employer.

Below is some information that may be useful in case you are seeking to learn the time it'll require you to fill out return work medical certification and what number of PDF pages it contains.

Question	Answer
Form Name	Return Work Medical Certification
Form Length	1 pages
Fillable?	Yes
Fillable fields	20
Avg. time to fill out	4 min 19 sec
Other names	medical certificate for work visa in forms, medical certification to return to work, medical certificates for work, medical certificate for work

12

Form Preview Example

Print Form

RETURN TO WORK CERTIFICATION

For Family and Medical Leave (FML)

SECTION I – To be completed by THE EMPLOYER

EMPLOYEE'S NAME (LAST, FIRST, MIDDLE INITIAL)

EMPLOYEE'S DEPARTMENT

DEPARTMENT CONTACT

DEPARTMENT CONTACT'S MAILING ADDRESS

PHONE

FAX

E-MAIL

SECTION II – To be completed by HEALTH CARE PROVIDER

NAME OF HEALTH CARE PROVIDER

ADDRESS

PLACE ADDRESS STAMP HERE:

PLEASE COMPLETE THE FOLLOWING AND RETURN THE FORM TO THE EMPLOYEE

OR TO THE DEPARMENT CONTACT LISTED ABOVE PRIOR TO THE RETURN TO WORK DATE

Important: Please limit your answers below to the serious health condition for which the Employee

has been on leave.

THE GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008 (GINA): 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.

1.Is the employee now able to perform those essential functions of his or her job that she could not previously perform because of the serious health condition for which the employee has been on leave?

No.

Yes.

Yes, with restrictions

2. Employee released to return to work effective: ____________________

[indicate date]

3.If the Employee is released to work but is restricted in his or her ability to perform the essential functions of his or her job as a result of the serious health condition for which the employee has been on leave, please describe those restrictions:

4.The foregoing restrictions are:

Permanent
Temporary, until: ____________________	[indicate date]

SIGNATURE

SIGNATURE OF HEALTH CARE PROVIDER

DATE

Print Form

How to Edit Return Work Medical Certification Online for Free

It really is easy to fill in the return to work medical certividate. Our PDF tool was built to be let you complete any document quickly. These are the four steps to follow:

Step 1: Hit the orange "Get Form Now" button on this web page.

Step 2: Once you've accessed the return to work medical certividate editing page you can discover every one of the actions you'll be able to perform regarding your template at the top menu.

Fill in the return to work medical cert, iv, i, date PDF by typing in the text necessary for every area.

stage 1 to completing fit for work medical certificate

Inside the box NoYes, Yes, with, restrictions indicate, date Permanent, Temporary, until indicate, date and DATE type in the details that the software requests you to do.

step 2 to filling out fit for work medical certificate

Step 3: Press "Done". Now you can transfer your PDF form.

Step 4: To prevent yourself from different headaches as time goes on, you will need to make a minimum of two or three duplicates of your form.

Watch Return Work Medical Certification Video Instruction

Return Work Medical Certification isn’t the one you’re looking for?

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .