Transcription of FITNESS FOR DUTY TO RETURN FROM LEAVE CERTIFICATION
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FITNESS FOR DUTY TO RETURN FROM LEAVE CERTIFICATION
EMPLOYEE NAME: _____ FML01 TBA - FMLA FITNESS for Duty CERTIFICATION Page 1 of 2 FITNESS FOR DUTY TO RETURN FROM LEAVE CERTIFICATION _____ An employee on family and Medical Leave1 because of his/her own serious medical condition must present this release to his/her supervisor prior to or on the day he/she returns to work. An employee may not work without this release. Please complete and RETURN form to TRISTAR Benefit Administrators via fax at 562-495-6687 TO: Health Care Provider Your patient, _____, began a period of medical care LEAVE for his/her serious health condition on _____. date employee commenced LEAVE ) As a condition of RETURN to work, the employee must have a medical examination.
EMPLOYEE NAME: _____ FML01TBA - FMLA Fitness for Duty Certification Page 1 of 2 FITNESS FOR DUTY TO RETURN FROM LEAVE CERTIFICATION _____ An employee on Family and Medical Leave1 because of his/her own serious medical condition must present this release to his/her supervisor prior to or on the day he/she returns to work.
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