TEXAS WOMAN’S UNIVERSITY
Office of Human Resources

Certification of Physician or Practitioner
REPORT OF MEDICAL STATUS/PHYSICIAN’S RELEASE
TO RETURN TO WORK

To:    Examining Physician             From:_____________________________________
                                                                                    Unit/Department Designee

Facility: __________________________    RE: ______________________________
                                                                                            Employee Name

It is our desire to assist your patient _________________________, our employee, to return to work as soon as possible, and to assist him/her in performing essential job functions at ____________________________.

This information is vital to any decision regarding:
A. the employee's working without risk of further injury;
B. the effect on his/her condition/illness;
C. availability of an alternate duty position that meets the employee's needs as well as

    those of the facility;
D. any reasonable, temporary, accommodations that can be made to aid the employee in

     performing his/her duties.
 

TO BE COMPLETED BY PHYSICIAN: (see reverse side for physical requirement of his/her duties)

            ___ Employee may return to FULL DUTY (no restriction) on: ______________
                                                                                                                      Date
            ___ Considering the limitations and having reviewed the job duties of this

                   employee:

                                ALTERNATE DUTY IS RECOMMENDED beginning on: ______
                                                                                                                                                                        Date
                                Length of alternate duty: ____________________________

            ___ Employee is to be OFF WORK until re-evaluated, beginning on: _________
                                                                                                                                                                    Date
                                Dates of covered absence: ______________________________

                                Next office visit: _________________________________

___________________________________
Physician's Signature                             Date

 

If you have any questions regarding the information requested on this form, please contact
________________________________         _______________________________
Name & Title                                                    Phone Number
 

TO BE COMPLETED BY UNIT/DEPARTMENT DIRECTOR:
According to limitations indicated by physician, employee is accepted for alternate duty:  ____ Yes ____ No
Alternate duty assignment is to begin: ________________ End: ___________________
Alternate duty assignment: _______________________________________________
 

INSTRUCTIONS TO THE EMPLOYEE: This completed form must be returned to the Unit/Department Designee immediately after each visit to physician.

The physical requirements below, marked with an "X", are those required of the employee in performance of his/her duties. Please mark the indicated column with a response of "Yes" if the employee can accomplish that specific task.
 

• DUTY - Supervisor indicates with an "X" those that are applicable.
• YES OR NO - Marked by Physician for each duty indicated by supervisor.
 

OTHER ACTIVITIES SPECIFIED BY SUPERVISOR
_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________



________________________      _______________________       _____________
Physician’s Name (Printed)             Physician’s Signature                     Date