Fill and Sign the Fitness for Duty Form

Fitness for Duty Certification Employee: ___________________________ SSN: ________________________ Location: ____________________________ Status: Full time ______ Part time ______ On leave since: ________ I hereby grant the Company permission to contact the health care provider completing this Fitness for Duty Certification for the purposes of certification and authentication. Signed:___________________________________________ Date: ______ Information below is to be completed by your health care provider Effective ________ the above named employee is hereby certified as fit to resume work duties as follows: Full time duties, no restrictions Full time duties with the following restrictions (please indicate conditions and duration):             Part time duties, no restrictions Part time duties with the following restrictions (please indicate conditions and duration):             Intermittent duties, with the following restrictions (please indicate conditions and duration):             Additional comments, if any:             Name of Health care provider: ___________________________________________ Type of practice/specialty: ______________________________________________ Address: ____________________________________________________________ Telephone: ___________________ Signature: _____________________________________________ Date: ______