State of colorado fitness-To-Return Certification

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State of Colorado Fitness-To-Return Certification 



Instructions to Employee:  Return this form to your department/institution before or on the day you return to 


Employee’s Name 

Employee ID #: 


Instructions to Department/Institution:  Attach the job duty statements from the official Position Description 

Questionnaire (PDQ).  This completed form is to be placed in a separate, confidential medical file with limited 



Pursuant to the Genetic Information Nondiscrimination Act (GINA)’s “safe harbor” provision in 29 CFR 

§ 1635.8(b)(1)(i), the GINA disclosure language must be included with any request for employment-related 

medical information or examinations (e.g., FMLA for employee, ADA, Fitness-for-Duty exams, Workers’ 

Compensation exams, post-offer/pre-employment exam, etc.) for the individual’s own condition. 


Instructions to Health Care Provider:  Please complete this form when the employee is seeking your release 

to return to work. 


The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities 

covered by GINA Title II from requesting or requiring genetic information of an individual or family 

member of the individual, except as specifically allowed by this law. To comply with this law, we are 

asking that you not provide any genetic information when responding to this request for medical 

information.  “Genetic information,” as defined by GINA, includes an individual’s family medical 

history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an 

individual’s family member sought or received genetic services, and genetic information of a fetus carried 

by an individual or an individual’s family member or an embryo lawfully held by an individual or family 

member receiving assistive reproductive services. 




Date the condition began.   


Check one of the following. 

 The employee is able to work a full, regularly scheduled day with no restrictions beginning  


 The employee is unable to return for any work until                (date). 

 The employee is able to return to work on a reduced schedule for            hours per day from              (date) 

through              (date). 

 The employee is able to return to work with restrictions from             (date) through           (date). 

Please complete next section (b). 


Please indicate restrictions. 


no lifting or carrying objects:             max. lbs.  Repetitions            


no pushing/pulling objects:             max. lbs.  Repetitions            


no bending/stooping/squatting/twisting:  Repetitions                 


no kneeling for more than            hours each day 


no crawling for more than            hours each day 


no sitting for more than            hours each day 


no standing for more than            hours each day 


no walking for more than            hours each day 


no climbing stairs 


no working/climbing on elevated equipment (ladders, stools, roofs, poles, etc.) for more than               

hours each day 


no reaching above the head or shoulders 


no reaching away from the body greater than                 with 


 left arm 


no grasping objects with   right   left hand 

Page 1 of 2 



Revised 2/18/11 

Print Form

Page 2 of 2 



Revised 2/18/11 


no fine manipulation with   right   left hand 


no assaultive, physical control, and/or arrest situations  


no driving a vehicle 


no operating machinery or equipment 


no working alone 


no use of firearms 


no typing, keyboarding, or entering data for more than                 hours each day 


no use of a CRT or computer monitor for more than                 hours each day 


no use, including repetitive, of                           (extremity/joint) 


no weight bearing on                           (extremity) 

      Other restrictions (specify):                                                                                          



Other instructions:   




Based on my personal evaluation of the patient’s condition, the above information is accurate and complete. 


Signature of Health Care Provider   



Printed Name 


Type of 







(   ) 


(   ) 







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