Disability Leave Return Medical Clearance Form

Disability Leave Return Medical Clearance Form — Form Fields

This hr template includes 11 fields. Collect medical provider clearance and any work restrictions prior to an employee returning from disability leave. Free to customize and use on ZenBuild.

• Employee Name (text, required)
• Job Title (text, required)
• Work Email (email, required)
• Attending Physician Name (text, required)
• Physician Phone Number (text, required)
• Date of Medical Clearance (text, required)
• Employee is cleared to return to work (multiple choice, required) — options: Full duty, Modified/restricted duty, Not yet cleared
• Work restrictions or limitations (if any) (long text, optional)
• Anticipated Duration of Restrictions (text, optional)
• Does the employee require workplace accommodations? (multiple choice, required) — options: Yes, No, To be determined
• Recommended accommodations (long text, optional)