State of colorado fitness-To-Return Certification
Yüklə 19,33 Kb.
|
- Bu səhifədəki naviqasiya:
- Instructions to Department/Institution
- Instructions to Health Care Provider
- Signature of Health Care Provider Date
| 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 work.
Employee’s Name Employee ID #:
Questionnaire (PDQ). This completed form is to be placed in a separate, confidential medical file with limited access.
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.
to return to work.
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.
1. Date the condition began. 2(a)
Check one of the following. The employee is able to work a full, regularly scheduled day with no restrictions beginning (date). 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). (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 right 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 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):
3. Other instructions:
Based on my personal evaluation of the patient’s condition, the above information is accurate and complete.
Address:
( )
( )
Email:
Yüklə 19,33 Kb. Dostları ilə paylaş:
|