Ours is very basic. Here are the fields we use:
For Employee to Complete:
Date Leave Commenced
Anticipated RTW Date
For Employee's Health Care Provider to Complete:
I certify that (employee name) is able to resume work on (date). I have received and reviewed a list of the essential functions of (employee name)'s position and certify that (employee name) is able to perform those functions.
Health Care Provider Name
We send this form along with a job description/essential duties description to the employee.
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