Arizona State Personnel System
HEALTH STATUS UPDATE AND/OR MEDICAL CLEARANCE FOR RETURN TO WORK
SECTION ONE - TO BE COMPLETED BY THE EMPLOYEE
SECTION TWO - TO BE COMPLETED BY THE HEAL TH CARE PROVIDER
Please only address the medical condition for which the employee used medical leave
WORK STATUS
Employee is unable to work starting (date)
Employee may work
modified
duty starting (date)
Number of hours per day employee may work
Does the employee have any permanent impairment or restrictions?
Date discharged from care
No
May work full duty with no restrictions (date)
EMPLOYEE'S FUNCTIONAL CAPACITY (Check only those that apply)
I
I
ASPS/HRD - FA6.04 06/08/18
