Download family leave

This document is provided as a courtesy to CIS members; it is an EXAMPLE of a document
used by some employers. It may or may not have had a legal review; and it may not
necessarily reflect your organization’s personnel rules, policies, practices, culture, or
collective bargaining agreements. You are welcome to use this document as an example, but
not necessarily as a model; adapt it to your own organization’s policies, practices, and
culture; and if you are unsure, you may want to have your final version reviewed by your
legal counsel.
This document does not take the place of consulting CIS’ Pre-Loss advice service. Some
examples of when to consult our advice service (but not limited to): 1) You are contemplating
a disciplinary action; 2) You are contemplating terminating an employee; or 3) You are
contemplating an action that may result in a liability claim or lawsuit. If you are not sure,
please call Kirk Mylander at (503) 763-3845, OR Janie McCollister (503) 763-3892.
Family Leave Fit for Duty Request: Employer Information Only
Distribute the Fit for Duty form (following pages) to the employee when notifying the
employee about the acceptance of his/her OFLA and/or FMLA leave request.
Please note: the Release to Share Health Information should only be given to the
employee if the employer needs the employer’s doctor to talk with the employee’s doctor,
to obtain clarification and authentication.
FAMILY LEAVE:
FIT FOR DUTY RELEASE
Employee Information
Employee’s Name:
Employee’s Address:
Employee’s Phone Number:
Employee’s Date of Birth:
(INSERT EMPLOYER NAME) Information
Employer Name:
Employer Address:
Billing Address if Different:
Employer’s Contact Phone Number:
Employer’s Contact Name:
Healthcare Provider Information
Name of Service Provider:
Address of Service Provider:
Service Provider Contact Phone Number:
Service Provider Contact Name (person to contact if there are questions about the
form after it is completed):
Date of Examination: ____________________________________________
I have reviewed the employee’s job description, including the essential functions of the
job, and based upon this information:
_____Employee is able to work without any restrictions:
Yes
No
_____Employee may perform his/her job duties, with the following restrictions or
accommodations:
Date employee is able to work without any restrictions: _________________
_____Employee is permanently impaired:
Yes No
Because of his/her impairment(s), the employee is unable to perform any of his/her
job duties:
Yes No
Additional Comments:
Service Provider’s Signature, Printed Name, and Date:
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."
INSERT NAME OF EMPLOYER
Health Information Sharing Employee Authorization Form
Purpose of this form: Allow Employer’s doctor to talk with Employee’s doctor (employer
will not talk directly with the employee’s doctor).
Employee’s Name
Employee’s Date of Birth
Employee’s Address
Employee’s Daytime Phone #
I authorize my healthcare provider _____________________________________________ to
disclose the information requested in this form to (INSERT NAME OF EMPLOYER’S
DOCTOR).
This authorization allows my healthcare provider to discuss my medical information with my
employer’s doctor, except for the exclusions listed in the box below.
I specifically exclude from this authorization, the following information:
I understand that the purpose of this disclosure is to determine my ability to perform the
essential functions of my job.
This authorization is valid until ____________________________________________________
I approve the use and sharing of “minimally necessary,” job-related health information, for my
employer to consider when evaluating my ability to perform my job.
Employee’s Signature
Date