Fillable Returnto Work Certification 000 (California Lutheran University)

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Returnto Work Certification 000 (California Lutheran University)

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The Returnto Work Certification 000 (California Lutheran University) form is 2 pages long and contains:

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  • 38 other fields

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File type: PDF

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CALIFORNIA LUTHERAN UNIVERSITY
MEDICAL LEAVE RETURN TO WORK CERTIFICATION
Dear Health Care Provider:
Thank you for evaluating our employee, ________________________________
Please review the attached job description.
1) Is the employee able to perform the essential functions of this job
without restrictions? ____Yes ____No
2) If yes, please indicate the date this employee may return to full
duties without restrictions: _____________________________.
If, in your medical opinion, this employee is not capable of performing essential functions
(attached), is the employee able to return to work with restrictions from ______________ (date)
through ____________?
Full-time_______ Part-time________ No_______
Please list the applicable restrictions or describe any accommodations which the
department should consider.
Lifting _______ Standing _______ Balancing ________
Kneeling _______ Sitting _______ Pushing ________
Twisting _______ Stooping _______ Concentration/Attention to Detail_____
Walking _______ Reaching _______ Reaching above head/shoulders______
Climbing _______ Crawling _______ Repetitive Motion________
Bending _______ Crouching _______ Handling/fingering _______
Operating machinery/equipment_______ Operating computer_______
Driving a car or other vehicle__________
Other restrictions (please specify):_______________________________________________
___________________________________________________________________________
___________________________________________________________________________
These restrictions are:
Permanent
Temporary
Anticipated date employee can return to full unrestricted duty______________________
Name of Health Care Provider__________________________________________________
(Please print or type)
Speciality____________________________________________________________________
Address_____________________________________________________________________
Signature_________________________________________ Date_____________________
Completed forms should be faxed to (805) 493-3655
Or mailed to: California Lutheran University
Human Resources Department
60 West Olsen Rd.
Thousand Oaks, CA 91360
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Returnto Work Certification 000 (California Lutheran University)

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Completed 20 July 2020

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