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Fitness For Duty Form - Fill and Sign Printable Template 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin with Section 1: Employee Information. Fill in your name, employment status, type of injury, last four digits of your SSN, date of birth, and S/O ID. Provide a brief description of your illness or injury along with the date of the incident and the first day you missed work.
- In Section 1, sign and date the authorization for your healthcare provider to release information. Include your cell phone number for contact purposes.
- Move to Section 2: Provider Information. This section must be completed by your healthcare provider. Ensure they fill in the exam date, time in/out, next appointment, diagnosis/comments, and work status.
- Your provider should specify any physical restrictions and anticipated return dates. They will also need to print their name, clinic/practice name, and provide their contact information before signing.
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Related links
This form is for return to work purposes of a medical leave of absence due to an illness or injury, whether work or non-work related.
The Department has developed optional-use forms. These forms are electronically fillable PDFs and can be saved electronically. There are five DOL optional-use