fitness for duty form

Does anyone have a sample "fitness for duty" form they can share?
Thank you.


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  • We have an outside nurse who receives the results of pre-employment physicals and sends me the following form letter. Not sure if this is what you mean.

    Date: 2-18-2011

    Employee Name:

    Date of Review:

    Description of Service: Medical Surveillance Form Review,

    Having reviewed the medical questionnaire form, she did not answer yes to any questions that require further intervention. She did not have any deficiencies on her tests and there are no further recommendations. XXXX Occupational Health Center examined this candidate and agrees that this person is fit to work at XXXX. A licensed medical professional did this review.


    Fit for Duty
  • Thanks for your response. I am thinking about the "fitness for duty" form we use for fmla. I was in the process of updating ours with the GINA safe harbor language, and am now rethinking the entire form in general, and wondered what others use. I seem to be receiving too many vague comments from the health care providers that make it difficult to determine if the employee can really return to work and under what limitations. I want to tighten up the language on the form overall.
  • An FMLA Fitness for Duty form is available to HRLaws subscribers at: [URL=" forms"] forms
    If you have trouble finding it, just let me know.

  • Ours is very basic. Here are the fields we use:

    For Employee to Complete:
    Date Leave Commenced
    Anticipated RTW Date
    Employee Signature/Date

    For Employee's Health Care Provider to Complete:
    I certify that (employee name) is able to resume work on (date). I have received and reviewed a list of the essential functions of (employee name)'s position and certify that (employee name) is able to perform those functions.
    Health Care Provider Name
    Telephone #
    Provider Signature/Date

    We send this form along with a job description/essential duties description to the employee.
  • Excellent. Thanks to you all. This is what I am looking for.
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