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? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | medical certificates for work, australian medical letter of certification for return to work, medical certification to return to work, return to work medical certividate |
RETURN TO WORK MEDICAL CERTIFICATION
FMLA LEAVE
PART 1: TO BE COMPLETED BY EMPLOYEE (please print or type)
Employee Name: __________________________________________ Date Leave Began: ________________________
(First Name, Middle Initial, Last Name)
Employee Position: __________________________________________________________________________________
Employee Signature: ______________________________________ Date: ____________________________________
PART 2: TO BE COMPLETED BY EMPLOYEE’S HEALTH CARE PROVIDER
I certify that on _________________, ___________________________________________ , is able to resume
(Date)(Name of Employee)
performing the functions of his/her position with or without reasonable accommodation.
Healthcare Provider Signature: ______________________________ Date: ______________________________
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