Human Resources 4220 80th Street NE; Marysville, WA 98270 Fax: 360-965-0079 MEDICAL CERTIFICATION FOR EMPLOYEE LEAVE OF ABSENCE Employee’s Name: Healthcare Provider’s Name: Provider’s Phone: Provider’s Fax: INFO Visit Date: Date of Injury: Diagnosis: GENERAL Employee is not released to any work from (enter dates): __________ to __________ Employee is restricted to modified duty, if available, from dates): __________ to __________ (complete modified duty section if selected) WORK STATUS Employee is released to work without restrictions as of (enter date): __________ Frequent Constant Seldom Occasional 34-66% 67-100% at Employee can: 1-10% 11-33% 3-6 (Not do (blank space = not restricted) 0-1 hour 1-3 hours hours restricted) Sit can Stand/Walk Perform work from ladder ladder Climb stairs employee Bend/Stoop the Crawl Reach Left, Right, Both what Work above shoulders L, R, B work Keyboard L, R, B Wrist (flexion/extension) L, R, B Grasp (forceful) L, R, B Fine manipulation L, R, B Estimate Operate foot controls L, R, B Vibratory tasks; high impact L, R, B Vibratory tasks; low impact L, R, B DUTY: Lifting/Pushing Never Seldom Occas. Frequent Constant Lift L, R, B lbs lbs lbs lbs lbs Carry L, R, B lbs lbs lbs lbs lbs Push/Pull L, R, B lbs lbs lbs lbs lbs MODIFIED Other Restrictions/Instructions: Physician’s Signature Date SIGN RETURN THIS COMPLETED FORM TO THE HUMAN RESOURCES DEPARTMENT: Name: Phone: E-Mail: Title: Fax:
Human Resources 4220 80th Street NE; Marysville, WA 98270 Fax: 360-965-0079 MEDICAL CERTIFICATION FOR EMPLOYEE LEAVE OF ABSENCE GENERAL INFO Employee’s Name: Healthcare Provider’s Name: Provider’s Phone: Provider’s Fax: Visit Date: Date of Injury: Diagnosis: WORK STATUS Employee is not released to any work from (enter dates): __________ to __________ Employee is restricted to modified duty, if available, from dates): __________ to __________ (complete modified duty section if selected) Employee is released to work without restrictions as of (enter date): __________ MODIFIED DUTY: Estimate what the employee can do at work Employee can: (blank space = not restricted) Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant 67-100% (Not restricted) Sit Stand/Walk Perform work from ladder ladder Climb stairs Bend/Stoop Crawl Reach Left, Right, Both Work above shoulders L, R, B Keyboard L, R, B Wrist (flexion/extension) L, R, B Grasp (forceful) L, R, B Fine manipulation L, R, B Operate foot controls L, R, B Vibratory tasks; high impact L, R, B Vibratory tasks; low impact L, R, B Lifting/Pushing Never Seldom Occas. Frequent Constant Lift L, R, B lbs lbs lbs lbs lbs Carry L, R, B lbs lbs lbs lbs lbs Push/Pull L, R, B lbs lbs lbs lbs lbs Other Restrictions/Instructions: SIGN Physician’s Signature Date RETURN THIS COMPLETED FORM TO THE HUMAN RESOURCES DEPARTMENT: Name: Phone: E-Mail: Title: Fax: