Fitness-for-Duty Evaluation Form
Employee Name
Employee ID
Position/Job Title
Department
Date of Evaluation
Evaluator Name
Reason for Evaluation
Essential Job Functions
Relevant Medical Information (if applicable)
Clinical Assessment
Evaluator Recommendation
Fit for Duty (No Restrictions)
Fit for Duty with Restrictions
Not Fit for Duty
If Restrictions, specify
Additional Comments
Evaluator Signature
Date