This is a template a healthcare provider can use to authorize the fitness and return to
employment of an injured employee. The provider can specify whether the employee is
fully able to resume working or whether they have restrictions. If the provider only
authorizes working with restrictions, they must include the restrictions in the space
provided. Additionally, it can be customized to provide for any additional industry
specific language that may be necessary. This template can be used by small
businesses or other entities that want to provide their healthcare provider with an
authorization form to determine the fitness of injured employees.
Return to Work Form
To be completed by healthcare provider prior to returning to work.
Fitness for Duty:
I have examined _________________________________ and can certify that he/she
___ fully able to resume working as of __________________________.
___ able to return to work on __________________ with the following restrictions:
Healthcare Provider’s Signature Type of Practice
Printed Name of Healthcare Provider Telephone Number
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