Occupational Health Fitness-for-Duty Evaluation Form
Please complete this form to assess an individual's occupational health fitness for duty. Only include information relevant to the evaluation.
Employee Full Name
*
First Name
Last Name
Job Title
*
Department
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Evaluation
*
Please Select
Routine assessment
Post-incident
Return to work
Job transfer
Other
Evaluator's Name
*
First Name
Last Name
Fitness-for-Duty Assessment
*
Fit for duty
Fit for duty with restrictions
Not fit for duty
Comments / Recommendations
Evaluator's Signature
Submit Evaluation
Submit Evaluation
Should be Empty: