About this template
A fitness for duty form is an essential tool for human resources teams, managers, and occupational health professionals. It is used to securely collect medical evaluations and clearance details when an employee is preparing to return to work following an illness, injury, or medical leave. This structured assessment helps organizations ensure workplace safety, verify that employees can safely perform their core duties, and document necessary workplace accommodations or restrictions.
Using Doc2Form, you can instantly turn this document into a ready-to-use Google Form, making it simple for treating physicians and employees to submit required medical evaluations online. The template covers critical details such as medical examination dates, healing status, work restrictions, anticipated return dates, and physician verification contacts. By streamlining this process digitally, HR teams can minimize administrative delays, maintain organized records, and support a smooth, safe transition back to the workplace.
Key features
- Collect medical clearance and return-to-work details securely
- Gather specific work restrictions and accommodations from treating physicians
- Standardize health evaluations across departments to ensure workplace safety
- Easily shareable with medical providers and employees via Google Workspace
Use cases
- Managing employee returns after major surgery or extended medical leave
- Evaluating physical readiness for high-risk or heavy machinery roles
- Documenting temporary workplace accommodations and modified schedules
What this form collects
- Employee Full Name (Short answer)Enter your first and last name.
- Phone Number (Short answer)Enter the best phone number to reach you.
- Email Address (Short answer)Enter your primary email address.
- Home Address (Paragraph)Provide your current residential address.
- Date of Medical Examination (Date)Select the date of your recent evaluation.
- Medical Facts Regarding Condition (Paragraph)Summarize the nature of the illness or injury as relevant to work capacity.
- Probable Duration of Condition (Short answer)Estimate how long the condition or recovery period is expected to last.
- Healing Period Completion Status (Multiple choice)Indicate whether the standard healing period is complete.
- Regular Job Duty Capability Status (Multiple choice)Can the employee perform all regular job duties without restriction?
- Essential Functions Concern Details (Paragraph)Describe any concerns regarding the employee's ability to perform essential job functions.
- Normal Work Schedule Ability Status (Multiple choice)Is the employee able to work their normal work schedule?
- Reduced Schedule Limits and Duration (Paragraph)If applicable, describe any schedule limitations and their expected duration.
- Return-to-Work Safety Risk Status (Multiple choice)Does returning to work pose any safety risk to the employee or coworkers?
- Work Restrictions List (Paragraph)List any specific limitations, lifting restrictions, or required accommodations.
- Proposed Return-to-Work Timing (Date)Select the intended date for the employee's return.
- Physician Name (Short answer)Enter the name of the evaluating physician or medical provider.
- Physician Phone Number (Short answer)Enter the contact phone number for the physician's office.
- Physician Email (Short answer)Enter the professional email address of the physician.
- Additional Comments (Paragraph)Provide any further notes or recommendations regarding the employee's return.
- Date Signed (Date)Enter today's date.
- Physician Signature (Short answer)Please paste a link to your signed document (Google Drive, Dropbox, etc.) or type the physician's full name as electronic confirmation.
FAQ
What is a fitness for duty form?
It is an evaluation document completed by a healthcare provider or employee to verify that an individual is medically cleared to safely resume their normal job responsibilities after an illness or injury.
Who is responsible for filling out this form?
Typically, sections of the form are completed by the employee and their treating physician or medical evaluator to outline specific restrictions, capabilities, and anticipated return dates.
Can I customize the questions in this Google Form template?
Yes! Once generated in Google Forms, you can fully edit, add, or remove questions to align with your company's specific HR policies and industry safety standards.
How does Doc2Form help me set up this form?
Doc2Form instantly converts structured form templates into fully functional Google Forms, saving you the time of building out complex medical and HR questionnaires from scratch.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.