Download East Baton Rouge Sheriff`s Office

Fitness-for-Duty Certification
East Baton Rouge Sheriff's Office
Post Office Box 3277
Baton Rouge, Louisiana 70821
Human Resources (225) 389-5163
Fax (225) 389-8979 or 389-8254
Section 1: Employee Information - to be completed by the Employee. (Please print)
Employee Name:
Employment Status:
Type of Injury:
Last Four SSN:
Reserve
Regular
School Crossing Guard
Duty Related Incident
Personal
DOB:
Part-time
Brief description of illness or injury:
Date of Incident:
/
/
First day missed work:
/
/
Job Location:
I hereby authorize my attending health care provider to release any information or copies thereof acquired in the course of my examination or
treatment for the injury above to my employer and/or its representative. I have read and understood the below work restrictions, after care
instructions and the authorization to release information.
Employee Signature
Employee Cell Phone
Date
Section 2: Provider Information - to be completed by Healthcare Provider. (Please print)
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 employees or their family members. In order 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.
Exam Date:
/
/
Time In:
/
/
Time Out:
/
/____
Next Appointment:
/
/____
Diagnosis/Comments:
Physical Ability:
The employee IS able to:
a.
Stand/Walk:
8 Hour Shift
12 Hour Shift
Other time restrictions:_______________________.
b.
Sit
8 Hour Shift
12 Hour Shift
Other time restrictions:_______________________.
c.
Drive
8 Hour Shift
12 Hour Shift
Other time restrictions:_______________________.
d.
bend
e.
use leg/knee/foot - right or left
reach
f. Use hands for:
squat/Kneel
climb stairs/ladders
perform overhead work
use shoulder/arm/hand - right or left
grabbing
pushing/pulling
fine manipulation
The employee IS able to lift or carry a maximum of ________________pounds.
Work Status:
A. The individual may return to work on
/
/
WITHOUT RESTRICTIONS.
B. The individual may return to work with the restrictions noted above on
The restrictions noted above are in effect until
C. The individual is UNABLE to work beginning
/
/
/
/
/
/
; Anticipated return date
.
/
/
.
Additional Restrictions/Comments: ___________________________________________________________________________
Physician Name (Print) :
Clinic/Practice Name:
Provider Phone/Fax:
Attending Physician Signature:
Effective date 08/12/03
Date:
R 03/13