Who may request this form?

Employers may request it when a physical is job-related and consistent with business necessity, such as after a conditional offer, return to work, or safety-sensitive reassignment. Ensure requests conform with ADA guidelines and company policy.

Is electronic signing allowed?

Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and most state UETA laws, provided intent, consent, attribution, and record retention are met.

What privacy protections are required?

Medical information is sensitive. Maintain confidentiality, limit access, and follow HIPAA rules where the employer is a covered entity or processes protected health information; execute a BAA when required.

What if the employee disagrees with findings?

Document the disagreement, consider a second medical opinion if policy allows, and follow established accommodation and appeals procedures to reduce liability.

When is notarization or witness needed?

Notarization is rarely required for physical requirement forms. If state law or a specific program demands notarization, follow that state's notary rules and retention requirements.

How long must I keep the record?

Retention depends on the document purpose: follow federal and industry rules such as HIPAA (6 years) and IRS or OSHA records as applicable; consult your retention schedule for specifics.

Electronic Signature
Templates
HR
Employee Physical Requirements

Employee Physical Requirements

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

EMPLOYEE PHYSICAL REQUIREMENTS ACKNOWLEDGMENT

Personal Information

Full Legal Name Home Address

Primary Phone

Email Address

Position Information

Job Title Department

Reporting Manager

Anticipated Start Date

Salary/Rate

Physical Requirements — Job Overview

The employer has determined the essential physical functions and environmental demands required for the position named above. The employee must be able to perform these functions with or without reasonable accommodation. The information below describes typical tasks, forces, frequencies, and environmental exposures that are essential to the position.

Primary essential functions (describe in detail)

Physical Tasks and Frequency

For each listed task, indicate requirement and approximate frequency: Constant (C), Frequent (F), Occasional (O), Rare (R), Never (N). If weight, distance, duration or other specifics apply, note in the adjacent field.

Lifting (maximum weight)

Requirement: Yes No

Max Weight: Frequency: Typical Duration:

Carrying / Pushing / Pulling

Requirements: Frequency:

Standing / Walking / Sitting

Standing: Walking: Sitting: Typical Shift Impact:

Stooping / Kneeling / Climbing / Crawling

Stooping: Kneeling: Climbing: Crawling:

Fine Motor / Repetitive Motion

Keyboarding / Repetitive Hand Use: Notes:

Vision / Hearing / Communication

Vision (near/far): Hearing:

Verbal Communication Required: Yes If yes, describe environment:

Environmental Conditions / Hazards

Exposure to temperature extremes, dust, chemicals, noise, heights, confined spaces, or blood-borne pathogens may occur:

Personal protective equipment required:

Medical Evaluation and Accommodation

The employer may require a fitness-for-duty examination by a designated medical provider to verify an employee's ability to safely perform essential functions. The employer will consider documented medical restrictions and make reasonable accommodations as required by law. The employer will not discriminate against employees based on disability; however, the employee must provide sufficient medical documentation to evaluate accommodation requests.

I consent to a fitness-for-duty medical evaluation if requested by the employer:

Yes No

If you have limitations or require accommodation, describe below

Employment History (Most Recent)

Provide at least two prior employers. Include duties that demonstrate ability to perform the physical requirements listed above.

Employer 1 — Company Name

Title

From

To

Primary Responsibilities Reason for Leaving Employer 2 — Company Name

Title

From

To

Primary Responsibilities Reason for Leaving

Education

Highest Degree or Certification Institution Graduation Date

References (Professional)

Reference 1 — Name

Phone

Email

Relationship

Reference 2 — Name

Phone

Email

Relationship

Reference 3 — Name

Phone

Email

Relationship

Legal Disclosures

At-Will Employment: If employed, the employment relationship is at-will, which means either the employee or the employer may terminate the relationship at any time, with or without cause or notice, unless modified by a written agreement signed by an authorized representative of the employer.

Equal Employment: The employer provides equal employment opportunity without regard to protected characteristics. Employment decisions are based on qualifications, job requirements, and business needs.

Authorization and Certification

I certify that all information provided in this document is true, complete, and correct to the best of my knowledge. I understand that falsification, omission or misrepresentation of information may be grounds for discipline or termination.

I authorize the employer to contact my former employers and listed references regarding my work history and to obtain information necessary to determine my ability to perform the essential functions of the job. I further authorize health care providers to disclose information necessary to evaluate my fitness for duty, consistent with applicable privacy laws.

I authorize pre-employment background checks and verification of the information provided

Yes No

By signing below I acknowledge that I have read and understand the physical requirements described in this document. I acknowledge that I have had the opportunity to ask questions regarding essential functions and physical demands, and that I will notify the employer immediately if I believe I cannot perform the essential functions, with or without accommodation.

Employee Printed Name:

Signature:

Date:

What the Employee Physical Requirements document is and why it exists

An Employee Physical Requirements document records the physical demands, limitations, and medical clearance status related to a specific job or task. Employers use it to document baseline fitness for duty, set accommodation discussions under the ADA, and record results of pre-placement or periodic physical examinations. The form typically accompanies a conditional job offer, return-to-work evaluation, fitness-for-duty exam, or job transfer. When handled electronically, the record should meet ESIGN (15 U.S.C. ch. 96) and applicable state e-signature rules to ensure enforceability and reproducibility.

Why documenting physical requirements matters

Clear documentation reduces workplace safety risks, supports reasonable accommodation decisions under the ADA, and creates an auditable record for OSHA and workers' compensation events. Properly completed forms also protect employers by clarifying job expectations and capturing medical clearance or restrictions.

Who typically prepares and uses this form

Typical users range across HR, occupational health, and frontline managers who need consistent evidence of physical fitness and restrictions.

Human resources teams responsible for hiring, onboarding, and accommodation tracking.
Occupational health providers conducting pre-placement and fitness-for-duty exams.
Supervisors and safety officers documenting job tasks and return-to-work limitations.

Use by the right teams helps integrate the document into hiring, onboarding, accommodation, and incident-response workflows.

Step-by-step: completing the Employee Physical Requirements

Follow these steps to collect, confirm, and record physical requirements consistently.

01

1. Initiate: Attach form to conditional offer or work order.
02

2. Assess: Occupational clinician documents tasks and exam results.
03

3. Record: Enter restrictions, clearance, and effective dates.
04

4. Store: Save in secure HR/medical record system with audit trail.

Common questions and answers about Employee Physical Requirements

Answers to frequent user questions about completion, legal concerns, and digital handling of Employee Physical Requirements.

Need help? Contact support

Who may request this form?
Employers may request it when a physical is job-related and consistent with business necessity, such as after a conditional offer, return to work, or safety-sensitive reassignment. Ensure requests conform with ADA guidelines and company policy.
Is electronic signing allowed?
Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and most state UETA laws, provided intent, consent, attribution, and record retention are met.
What privacy protections are required?
Medical information is sensitive. Maintain confidentiality, limit access, and follow HIPAA rules where the employer is a covered entity or processes protected health information; execute a BAA when required.
What if the employee disagrees with findings?
Document the disagreement, consider a second medical opinion if policy allows, and follow established accommodation and appeals procedures to reduce liability.
When is notarization or witness needed?
Notarization is rarely required for physical requirement forms. If state law or a specific program demands notarization, follow that state's notary rules and retention requirements.
How long must I keep the record?
Retention depends on the document purpose: follow federal and industry rules such as HIPAA (6 years) and IRS or OSHA records as applicable; consult your retention schedule for specifics.

Core sections to include in a professional Employee Physical Requirements form

A complete form groups employee identifiers, job demands, medical findings, and administrative controls; each section should be clear and auditable.

Employee Details

Full legal name, employee ID, department, and contact details to ensure accurate linkage to personnel files and benefits records.

Job Demands

Specific physical tasks, frequency, duration, and measurable limits such as weights, distances, or hours of standing.

Medical Evaluation

Clinician findings, required tests, clearance status, and any recommended restrictions or assistive devices.

Workplace Accommodations

Document proposed accommodations, expected duration, and follow-up review dates to support ADA compliance.

Signatures

Employee, clinician, and authorized employer representative signatures with dates and, where used, e-signature method recorded.

Record Notes

Audit entries for amendments, review history, and access logs to establish a defensible document trail.

Security and privacy elements to protect medical data

Encryption: TLS 1.2/1.3 in transit

Data at rest: AES-256 encryption

Access controls: Role-based access

Audit trail: Timestamps and IP logs

HIPAA support: BAA available where required

Standards: SOC 2 Type II and ISO 27001

Legal and operational risks of incorrect or missing documentation

ADA exposure: Discrimination claims

Workers' comp: Benefit disputes

OSHA fines: Workplace safety penalties

HIPAA breach: Regulatory penalties

Recordkeeping: Loss of evidence

Operational impact: Scheduling and liability gaps

Common mistakes to avoid when preparing the form

Using vague physical descriptions rather than measurable limits, which weakens accommodation decisions and enforcement.
Failing to obtain documented medical clarification for ambiguous restrictions, leading to inconsistent work assignments and disputes.
Storing medical details in unsecured systems or shared HR folders without role-based controls and audit logs.
Not documenting employee consent for electronic records or failing to provide required ESIGN consumer disclosures for covered transactions.

Typical submission and review workflow for the form

A standard workflow streamlines request, assessment, approval, and storage while preserving auditability for compliance reviews.

Request: HR generates form and routes to clinician.
Examination: Clinician completes assessment and records findings.
Approval: Employer reviews restrictions and approves accommodations.
Archive: Store securely with access logs retained.

Configuring an electronic workflow for Employee Physical Requirements

Consider these settings when creating a digital workflow to ensure secure capture, signer verification, and proper retention.

Field	Configuration
Document Template	Use a locked template with fillable fields and version control.
eSignature Method	Email link or authenticated eSign per ESIGN requirements.
Authentication	Email + SMS or advanced ID verification for clinicians.
Retention Policy	Automatic archive with configured retention and access logs.

Digital platform requirements and file formats

Choose a platform that supports secure PDF/Word uploads, reliable audit trails, and appropriate authentication options.

File formats: PDF, DOCX supported
Integrations: Works with Salesforce, NetSuite, Google Workspace
Access control: SSO/SAML and role-based permissions

Practical timing: when to request and review the physical requirements

Timely collection ensures fitness assessments inform start dates, accommodation planning, and incident response without delaying operations.

Before start date:

Collect pre-placement exam after conditional offer, before first shift.

Return-to-work:

Request clearance promptly after medical leave ends to plan accommodations.

Post-incident:

Obtain assessment immediately following workplace injury for safety decisions.

Periodic review:

Schedule reassessments based on job risk or clinical recommendation.

Record updates:

Update form on any material change to duties or health status.

Comparing eSignature vendors for Employee Physical Requirements workflows

This high-level comparison summarizes starting prices and selected feature indicators; verify vendor plan details before purchasing to confirm HIPAA options and volume limits.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes (tiered)	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA)	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

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