FMLA Return to Work Medical Evaluation - the University System of Georgia
This letter is in reference to
Return to Work
our employee and your patient. We are investigating the eligibility of this employee to return to work follo wing a “serious health
condition, which made the employee un able to perform the functions of such employee’s position.”
A “serious health conditi on” when utilized as a basis for family leave, means an illness, inj ury, impairment, or physical or mental
condition invol v ing either inpatient care in a hospital, hosp ice, or residential health care facility, or continuing treatment by a health
The essential functio ns of this emplo yee’s j ob are as follo ws. Please indicate in your opinion if he/she will b e able, or not, to perform
these functions, and any restrictions you recommend, as of the expected return to work date of _______ _________________ .
To be completed by supervisor To be completed by health care provider
Thank you for your help in this process. Should you have any questions regarding this request, please contact me directly.
_______________________ _____________ ____________________________ ________________ ________________ _______
In your opinion , when will he/she be able to return
to work and resume his/her normal duties?
Name of health care provider ___________________________________ ________________ Phone _____________ __________
Signature ___________________ _________________________ Date ______________ _________
Patient/employee sig nature authorizing re lease of this information
Please return this completed form to the
patient, in person or to the following address:
FMLA Return to Work Medical Evaluation - the University System of Georgia PDF
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