Fitness For Duty Form Template

Return-to-work decisions need a clear clinical call, not a vague email. This fitness for duty form template records exam date, clearance status, and any work restrictions so HR and the employee share one record.

Great for

• Occupational health clearing employees after injury or illness
• HR collecting a structured provider note before return to work
• Safety-sensitive roles that need a documented fitness decision

Keep the form focused on clearance and restrictions. Detailed diagnosis belongs in the medical chart, not on the copy HR needs to schedule shifts.

Share the link with the examining provider. Export responses when payroll or safety needs a dated record of the decision.

Formms is not built for HIPAA-covered records. If your organization is a covered entity, use a HIPAA-compliant platform for this workflow instead.

Questions in this template

1. Employee full name *
   Name
2. Job title or department *
   Short text
3. Exam date *
   Date
4. Fitness for duty status *
   Dropdown Fit for full duty, Fit with restrictions, Not fit for duty at this time, Needs further evaluation
5. Work restrictions or accommodations *
   Long text
6. Restrictions end date (if known)
   Date
7. Examining provider name *
   Name
8. Provider signature *
   Signature
9. Today's date *
   Date