Fitness For Duty Return To Work Form - Collin College
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1Fitness for Duty/Return to Work Form
Medical authorization from attending physician is required for employees returning to work from family and
medical leave. This form must be returned to the Human Resources prior to or before returning to work.
Employee Section
Employee Name/Patient: (Last, First) _____________________________________
Date of Injury/Illness: __________________________________________________
CWID: _____________________________
Physician Section
May resume work immediately with no restrictions
May resume work immediately with the following restrictions:
Sedentary work (sitting, occasional walking, standing, lifting less than 10 lbs.)
Light work (lifting less than 20 lbs.)
Medium work (lifting less than 50 lbs.)
Heavy work (lifting less than 100 lbs.)
He/She is released to work:
_______ Hours per day
His/Her normal shift
He/She may return to work at full duty on (date) _
______
He/She has a return appointment on (date) and (time) _______ at (time) _______
_________________________________
_________________________________
Physician Signature
Physician Name (print)
_________________________________
_________________________________
Date
Phone Number (include area code)
_________________________________
_________________________________
Street Address
City, State and Zip Code
Collin College, Human Resources Department, Collin Higher Education Center,
3452 Spur 399, McKinney, Tx 75069 Fax: 972-985-3778
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