Fitness For Duty Form - Fill and Sign Printable Template: Fill out & sign online

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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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Versions	Form popularity	Fillable & printable
2013	4.9 Satisfied (37 Votes)
2012	4.4 Satisfied (44 Votes)

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