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Fitness for Duty Form
Without a release from my health care provider.
Employee's Signature:
Date:
This section to be completed by the Health Care Provider:
I have examined the employee named above and certify that this person is medically able to resume working on:
This employee can return to work:
With No Restrictions
With Restrictions (outline details below)
If the employee is returning with restrictions, please state in detail the employee’s restrictions and the duration of
these restriction:
Signature of...
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