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Fitness For Duty Form Template

Streamline Employee Readiness Assessments with Our Fitness For Duty Form

Wondering if your workers are ready to return after illness or injury? This Fitness for Duty Form Template is designed for employers like you, ensuring your team members are fit to work before stepping back into their roles. With this template, you can easily evaluate employee readiness, maintain workplace safety standards, and streamline your return-to-work processes, all while ensuring compliance with legal requirements. Plus, the WCAG-aligned labels make it accessible for everyone. Try out the live template to see how it can simplify your assessments.

Use this Template (FREE) Live Preview
Employee full name
Employee ID or number
Job title
Department or location
Supervisor full name
Employer contact email
Reason for this evaluation
Post-injury or illness
Return-to-work clearance
Post-incident or near-miss
Periodic fitness certification
Job transfer or change in duties
Other
Please Specify:
Date of event or onset (if applicable)
Last day worked
Summary of essential job tasks
Is this a safety-sensitive position?
Yes
No
Current work status
Fit for duty without restrictions
Fit for duty with restrictions
Not fit for duty at this time
Pending further evaluation
Primary functional limitations (select all that apply)
Please Specify:
Maximum lifting limit
No lifting restriction
Up to 10 lb
Up to 20 lb
Up to 30 lb
Up to 50 lb
Over 50 lb
Not applicable
Unknown
Work hours capacity
Full shift
Up to 4 hours/day
Up to 6 hours/day
Alternate or light duty only
No work
Not applicable
Unknown
Prohibited activities (select all that apply)
Please Specify:
Restrictions effective until
Re-evaluation recommended on or after
Comments for employer (scope: work capacity only)
Recommended accommodations (select all that apply)
Please Specify:
I acknowledge that the information I provided for this evaluation is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Employee typed signature (full name)
Employee signature date
I authorize the release of this fitness-for-duty determination (not underlying medical records) to my employer.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Provider full name
Professional title or credentials
Facility or clinic name
Provider phone number
Provider typed signature (full name)
Provider signature date
I certify this assessment reflects my clinical judgment based on the information available today.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Return-to-work start date
Notes or accommodation plan
Reviewer full name
Reviewer typed signature (full name)
Review date
Employer decision
Approved to return without restrictions
Approved to return with accommodations
Temporary alternate duty assigned
Not approved to return at this time
Pending clarification
{"name":"Employee full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Employee full name, Employee ID or number, Job title","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a Fitness For Duty form with an emphasis on health and workplace readiness.

When to use this form

Use this form when an employee returns after illness or injury, shows signs of impairment at work, or works in a safety-sensitive role. You, your supervisor, and occupational health use it to confirm readiness, document restrictions, and set a safe plan. Common scenarios include a driver cleared after a concussion, a nurse recovering from respiratory illness, or a technician whose new medication may cause drowsiness. For complete context, pair it with a Health screening form for baseline vitals, a Pre employment physical form for new hires, and a Medical chart review form when you need provider documentation. The outcome is a clear, documented decision that protects the employee and the team.

Must Ask Fitness For Duty Questions

  1. What are your essential job tasks and the typical hazards you face?

    This defines the physical and cognitive demands you must meet. Clear context helps reviewers judge risk and match any limits to real tasks.

  2. Have you had any recent illness, injury, surgery, or medication changes that could affect safe job performance, and when did these start?

    A simple timeline shows progress and remaining risk. Dates help distinguish temporary issues from ongoing conditions that might limit duty.

  3. What work restrictions or accommodations has your healthcare provider recommended, and for how long?

    This clarifies limits (lifting, hours, exposure) so you can assign duties that match capacity. If a staged schedule is needed, you can align it with a Phased return to work form.

  4. Can you safely wear all required protective equipment (for example, an N95 respirator) for your full shift?

    PPE tolerance is critical in healthcare, lab, and industrial roles. If a respirator is required, results from an N95 Fit-test form support the decision.

  5. Do you authorize us to review relevant medical notes to confirm your clearance and restrictions?

    Consent lets your team verify clinical guidance without over-sharing. It speeds decisions and helps you meet privacy and documentation standards.

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