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How do I fill this out?
To complete this form, you need to provide your personal and job-related information, and then have your healthcare provider attest to your fitness for duty. Submit the completed form to your employer for approval. Detailed instructions are provided in the subsequent sections.
How to fill out the Fitness-for-Duty Certification Form?
1
Fill out Section 1 with your personal and job-related information.
2
Give the form to your healthcare provider to complete Section 2.
3
Ensure the healthcare provider includes all necessary information and signs the form.
4
Submit the completed form to your employer.
5
Await confirmation of your return-to-work approval.
Who needs the Fitness-for-Duty Certification Form?
1
Employees returning to work after medical leave need this form to certify their fitness for duty.
2
Supervisors require this form to ensure their employees can safely perform their job duties.
3
Human Resource departments use this form to maintain compliance with company policies.
4
Healthcare providers use this form to communicate their patient's ability to return to work.
5
Employees with temporary or permanent work restrictions need this form to outline their limitations.
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What are the instructions for submitting this form?
Submit the completed Fitness-for-Duty Certification form via fax to (305) 348-3884, email it to hrleaves@fiu.edu, or deliver it in person to PC 224. Ensure the form is submitted no more than five days before your intended return-to-work date.
What are the important dates for this form in 2024 and 2025?
The Fitness-for-Duty Certification form should be completed and submitted no more than five days prior to returning to work.
What is the purpose of this form?
The purpose of the Fitness-for-Duty Certification form is to ensure that employees returning to work after a medical leave are capable of performing their job duties safely and effectively. This form is essential for maintaining workplace safety and compliance with company policies. By providing detailed information about an employee's fitness for duty, employers can make informed decisions and accommodate any necessary restrictions or modifications.
Tell me about this form and its components and fields line-by-line.
- 1. Employee name: The full name of the employee completing the form.
- 2. Employee Panther ID: The unique identifier for the employee.
- 3. Employee Position Title: The job title of the employee.
- 4. Campus Phone #: The contact phone number for the employee's campus location.
- 5. Supervisor's Name: The name of the employee's supervisor.
- 6. Supervisor's phone # or email: The contact information for the employee's supervisor.
- 7. Phone # where employee can be reached: A phone number where the employee can be contacted.
- 8. Employee FIU email: The official FIU email address of the employee.
- 9. Alternative email: An alternative email address for the employee.
- 10. Healthcare Provider Signature: The signature of the healthcare provider completing the form.
- 11. Date: The date when the healthcare provider completed the form.
- 12. Name of Healthcare Provider: The full name of the healthcare provider.
- 13. Type of Practice/Medical Specialty: The medical specialty or type of practice of the healthcare provider.
- 14. Address: The address of the healthcare provider's office.
- 15. Telephone number/E-Mail Address: The contact information for the healthcare provider.
What happens if I fail to submit this form?
Failing to submit the Fitness-for-Duty Certification form may delay your return to work.
- Delayed Return: Your return to work may be delayed until the form is submitted.
- Non-Compliance: Failure to comply with company policies regarding fitness-for-duty certifications.
How do I know when to use this form?
- 1. Medical Leave: After returning from any medical leave to certify ability to work.
- 2. Work Restrictions: When there are specific work restrictions or accommodations needed.
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