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Return To Work Certification Form
"Need a Return To Work Certification Form for an employee returning from a long-term disability leave, with specific accommodations for reduced lifting capacity and modified work hours to be implemented from March 2025."
1. Employee Information: Basic identifying information about the employee including name, employee ID, department, and position
2. Leave Details: Information about the leave period, including start date, end date, and reason for leave
3. Medical Provider Certification: Healthcare provider's assessment of employee's ability to return to work, including any evaluations and clearances
4. Work Capacity Statement: Clear statement of whether employee can return to full duty or requires restricted duty
5. Return Date: Specific date of return to work and any phased return schedule if applicable
1. Accommodation Requirements: Details of any workplace accommodations needed for the employee's return, including specific modifications or restrictions
2. COVID-19 Certification: Specific pandemic-related health certifications and protocols that must be followed upon return
3. Temporary Restrictions: Detailed list of temporary work restrictions or modifications needed for a gradual return to work
1. Medical Documentation: Attached medical records, provider notes, or other supporting documentation
2. Accommodation Plan: Detailed plan outlining implementation of required accommodations and timeline
3. Job Description: Current job requirements and essential functions for medical provider review
Authors
Authorized Healthcare Provider
Essential Job Functions
Fitness for Duty
Full Duty
Leave Period
Medical Certification
Modified Duty
Physical Restrictions
Protected Health Information
Qualified Healthcare Provider
Reasonable Accommodation
Return to Work Date
Restricted Duty
Temporary Restrictions
Work Capacity
Work Limitations
Work Release
Workers' Compensation
Workplace Modifications
Work Capacity Statement
Physical Limitations
Workplace Accommodations
Confidentiality
Medical Privacy
Return Date
Duty Modifications
Safety Requirements
Follow-up Evaluations
Duration of Restrictions
Compliance with Medical Instructions
Employee Acknowledgment
Healthcare Provider Authorization
Employer Rights
Documentation Requirements
Fitness for Duty
Work Schedule Modifications
Medical Information Release
Certification Validity Period
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