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.

QuestionAnswer
Form NameReturn Work Medical Certification
Form Length1 pages
Fillable?Yes
Fillable fields20
Avg. time to fill out4 min 19 sec
Other namesmedical certificate for work visa in forms, medical certification to return to work, medical certificates for work, medical certificate for work

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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

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