Fmla Fitness For Duty Form
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Attached are the essential functions of the employees position.
Fmla fitness for duty form. Return completed form to employer prior to returning to work. Fitness for duty certification. Karen passanisi last modified by. Employee information and informed consent for disclosure of health care information name telephone number address statement of physician or practitioner medical facts regarding patients condition.
If i am on unpaid fmla leave not including disability leave i will be required to exhaust all other paid time off vacation sick days personal days. To be completed by employee i give permission to my health. You are required to provide a fitness for duty certification prior to returning to work after an approved fmla leave of absence due to medical reasons ie. And if i am on fmla leave for my own serious health condition i will submit a fitness for duty certification prior to returning to work.
Please have the health care provider who is knowledgeable regarding your reason for using fmla leave andor workers compensation leave complete this form and return. Return completed form to the employees human resources department contact information will be provided by employee genetic information nondiscrimination act of 2008 notification. Please have your health care provider complete this form and return it to human resources by. Fitness for duty university policy office.
Fitness for duty form employee. Having observable difficulty performing work duties in a manner that is safe for the employee for the employees coworkers for the university or for the public as determined by. Certification forms the fmla does not require the use of any specific certification form. The department has developed optional forms that can be used for leave for an employees own serious health condition wh 380 e or to care for a family members serious health condition wh 380 f or the employer may use its own forms.
City and county of san francisco fmla 7 1. Probable duration of condition. 11 days ago the purpose of this policy is to establish procedures by which the university will evaluate an employees fitness for duty when an employee is. Fitness for duty to return from leave certification.
Ray cordoba created date. Fitness for duty subject. Dhr fmla 7 rev. The genetic information nondiscrimination act of 2008 gina prohibits employers and other entities covered by gina title ii from requesting or requiring genetic information of.
Forms wh 380 e certification of health care provider for employees serious health condition pdf wh 380 f certification of health care provider for family members serious health condition pdf. 652006 71600 am company. Serious illness workers compensation short term disability etc. If an employer provides the notice required an employee who does not provide a fitness for duty certification or request additional fmla leave is no longer entitled to reinstatement under the fmla.
If the employer chooses to use its own forms it may not. Fitness for duty.
