Fmla Fitness For Duty Form
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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.
Fmla fitness for duty form. Dhr fmla 7 rev. 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 employer prior to returning to work. To be completed by employee i give permission to my health.
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. Fitness for duty subject. 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. Fitness for duty form employee.
Karen passanisi last modified by. You must return this completed fitness for duty certification form to human resources as requested or your return to work may be delayed or denied under the fmla. 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. Attached are the essential functions of the employees position.
Fitness for duty certification. Dhr fmla 7 rev. 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. Ray cordoba created date.
Fitness for duty to return from leave certification. 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. City and county of san francisco fmla 7 1. 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.
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. 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. Probable duration of condition. Return completed form to the employees human resources department contact information will be provided by employee genetic information nondiscrimination act of 2008 notification.
Certification forms the fmla does not require the use of any specific certification form. Please have your health care provider complete this form and return it to human resources by. Fitness for duty university policy office. 62006 this is a 2 sided document.
Fitness for duty. 652006 71600 am company.
