Return to Work Medical Clearance Form
This form must be completed and signed by the treating healthcare provider to confirm the employee is medically cleared to return to work.
Employee Information
Employee Full Name
*
First Name
Last Name
Employee Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Job Title / Position
*
Department or Work Location
Expected Date of Return to Work
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Section
This section must be completed and signed by the treating healthcare provider. Please confirm the employee’s medical clearance to return to work.
Provider Full Name
*
First Name
Last Name
Provider Contact Information (Phone or Email)
*
Medical Clearance Statement
*
Employee is medically cleared to return to work with no restrictions.
Employee is medically cleared to return to work with restrictions (please specify below).
Employee is not medically cleared to return to work at this time.
If restrictions apply, please specify
Date of Clearance
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Signature
*
Submit Medical Clearance
Submit Medical Clearance
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