Southwest Virginia Community College Nursing Program
Fitness for Duty- Return to Classroom and Clinical Courses
Form B
Student Name:
This form is required for all students who have experienced an illness, injury, pregnancy, hospitalization
or other circumstance which resulted in either a physical or psychological limitation(s) or an absence
from the program.
Please use the following information to determine if this student can return to the classroom and clinical
Each clinical day is 8-12 hours in length
Students are expected to complete nursing care activities comparable to that of a staff nurse
with the supervision of their clinical instructor
Physical demands in the nursing program include duties that frequently require squatting,
bending, kneeling, reaching, and stair climbing, lifting and carrying up to 50 pounds; frequent
pushing and pulling up to 200 pounds with assistance; occasional lifting up to 200 pounds with
assistance and occasional carrying up to 51-74 pounds. Duties also require constant use of sense
of sight, hearing, touch, and speech. Environmental conditions include procedures that involve
handling blood and body fluids using standard (universal) precautions
Please indicate your recommendation regarding this student’s ability to return to the
classroom/clinical setting. The student must be free of any restrictions or limitations which may
endanger the student’s health or a client’s safety in the clinical setting.
I find the above named student fit for duty with NO restrictions or limitations in the classroom
or clinical setting
I find the above named student fit for duty WITH the following restrictions or limitations:
I find the above named student NOT fit for duty; may reconsider after (date)
Healthcare Provider Signature/Title: