Return to work from MEDICAL LEAVE

 

 

MEDICAL LEAVE – RETURN TO WORK FORM

NOTE:  This form must be completed for any serious health condition of the employee prior to their return to work. 

 

PART I:  EMPLOYEE INFORMATION (to be completed by Employee)

 

Employee Name:		PID #:
Dept Name:		Dept #:
CB #:		Work Phone:
Home Address:		Home Phone:

 

PART II:  MEDICAL RETURN TO WORK CERTIFICATION (to be completed by the Health Care Provider)

 

Name of Health Care Provider:
Name of Health Care Practice:
Address:
Phone:		Date of Examination:
Name of Employee:		Name of Patient:
Date employee is released to return to work: Note: If an employee is returning to work on a reduced or intermittent work schedule, do not complete this form. Instead, complete “U.S. Department of Labor Certification of Health Care Provider for Employee’s Serious Health Condition Form” for the employee to submit with “Medical Leave – Leave Request Form”
Is the employee able to perform the essential functions of his/her position as of the return to work date?				YES                  NO
Additional Comments:
CERTIFICATION:  I affirm that the information provided above is true and accurate to the best of my knowledge.
Signature-Health Care Provider:			Date:

 

PART III:  CERTIFICATION OF RETURN TO WORK (to be completed by HR Representative)

Date Leave of Absence (or reduced/intermittent schedule) Began:
Date Employee Returned to Work at Regularly Scheduled Hours: Note: If an employee is returning to work on a reduced or intermittent work schedule, do not complete this form. Instead, complete a new “Medical Leave – Leave Request Form” and check the “Supplement to Previous Request” box at the top right corner.
Hours of Unused Shared Leave Donations to Be Returned: NOTE: Employee may retain up to 40 hours of donated leave.
Employee IS NOT returning to work.  Separation Date is:

 

HR Representative’s Signature:

Date:

 

FOR FACULTY, SPA AND EPA NON-FACULTY:  Forward this document, along any other supporting documentation to: