Fillable Printable FMLA Return to Work Medical Evaluation - the University System of Georgia

FMLA Return to Work Medical Evaluation - the University System of Georgia

Dear :

This letter is in reference to

Human Resources

FMLA

Return to Work

Medical Evaluation

Clear form

Date

our employee and your patient. We are investigating the eligibility of this employee to return to work follo wing a “serious health

condition, which made the employee un able to perform the functions of such employee’s position.”

A “serious health conditi on” when utilized as a basis for family leave, means an illness, inj ury, impairment, or physical or mental

condition invol v ing either inpatient care in a hospital, hosp ice, or residential health care facility, or continuing treatment by a health

care provider.

The essential functio ns of this emplo yee’s j ob are as follo ws. Please indicate in your opinion if he/she will b e able, or not, to perform

these functions, and any restrictions you recommend, as of the expected return to work date of _______ _________________ .

To be completed by supervisor To be completed by health care provider

JOB TASK/RESPONSIBILITY

Yes

RESTRICTIONS

Thank you for your help in this process. Should you have any questions regarding this request, please contact me directly.

_______________________ _____________ ____________________________ ________________ ________________ _______

Supervisor name

In your opinion , when will he/she be able to return

to work and resume his/her normal duties?

Title Phone

Name of health care provider ___________________________________ ________________ Phone _____________ __________

Signature ___________________ _________________________ Date ______________ _________

Patient/employee sig nature authorizing re lease of this information

Please return this completed form to the

patient, in person or to the following address:

Patient name

Patient address

Revised 04/2008