Fitness For Duty Form
Employee Information
Employee Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Medical Examination
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Statement of Physician / Practitioner
Medical Facts Regarding Patient's Condition
Probable Duration of Condition
Has the patient completed their healing period?
Yes
No
Can the patient perform all the duties of their regular job?
Yes
No
If the essential functions were listed, please specify if any of them raise concerns considering the employee's current condition.
Is patient able to work his/her normal work schedule?
Yes
No
Please indicate the maximum number of hours per day and per week that the patient is able to work, as well as the anticipated duration of the reduced schedule period.Please identify the number of hours per day and the number of hours per week that the patient can work, and the expected duration of the period for the reduced schedule.
Is the patient able to return to work without posing a significant risk or substantial harm to him/herself or others?
Yes
No
When can patient return to work?
Please List the Restrictions
Additional Comments
Physician Information
Physician Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Physician
Submit
Should be Empty: