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FMLA Return to Work Form
Employee Information
Employee Name
*
Department
*
A
HOU
B
AUS
C
Other
Phone
*
Employee ID/Number
*
Job Title
*
Email
*
Acknowledgement
I am prepared to return to work from my FMLA Leave on:
*
Is your FMLA Leave due to your own illness?
*
A
Yes
B
No
Medical Certification Requirement:
If the leave involved the employee’s own serious health condition, a fitness for duty certification may be required before returning to work. If you have a Doctor's Note, you may submit it below.
Name of Doctor
*
Date of Medical Clearance:
*
Clinic/Hospital
*
Medical Documentation
*
Click to choose a file or drag here
Workplace Accommodations
Are there any specific work limitations/restrictions or accommodations needed?
*
A
Yes
B
No
Accommodation Request
*
Description of Accommodation
*
Additional Comments or Notes
*
Certification
*
I am able to resume all job duties.
Employee's Acknowledgment
Employee Signature
*
Sign here
Date
*
Submit