FITNESS-FOR-DUTY MEDICAL CERTIFICATION
TO RETURN TO WORK FROM FAMILY/MEDICAL LEAVE OF ABSENCE
The purpose of this form is to certify that the employee is fit to return to work if the serious health condition and reason
for the leave was related to one of the following:
• Communicable diseases including, but not limited to hepatitis, AIDS, tuberculosis
• Surgery requiring hospitalization or work restrictions
• Medical/psychological conditions requiring ongoing office visits and treatment, including, but not limited to, cancer,
chemotherapy, dialysis, bipolar disorders
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Last modified: February 2, 2007