Employee ID #:
Instructions to Department/Institution: Attach the job duty statements from the official Position Description
Questionnaire (PDQ). This completed form is to be placed in a separate, confidential medical file with limited
Pursuant to the Genetic Information Nondiscrimination Act (GINA)’s “safe harbor” provision in 29 CFR
medical information or examinations (e.g., FMLA for employee, ADA, Fitness-for-Duty exams, Workers’
Compensation exams, post-offer/pre-employment exam, etc.) for the individual’s own condition.
Instructions to Health Care Provider: Please complete this form when the employee is seeking your release
to return to work.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities
The employee is able to work a full, regularly scheduled day with no restrictions beginning
The employee is unable to return for any work until (date).
The employee is able to return to work on a reduced schedule for hours per day from (date)
The employee is able to return to work with restrictions from (date) through (date).
Please complete next section (b).
Please indicate restrictions.
no lifting or carrying objects: max. lbs. Repetitions
no pushing/pulling objects: max. lbs. Repetitions
no bending/stooping/squatting/twisting: Repetitions
no kneeling for more than hours each day
no crawling for more than hours each day
no sitting for more than hours each day
no standing for more than hours each day
no walking for more than hours each day
no climbing stairs
no working/climbing on elevated equipment (ladders, stools, roofs, poles, etc.) for more than
no reaching above the head or shoulders
no reaching away from the body greater than with
no grasping objects with right left hand
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no fine manipulation with right left hand
no assaultive, physical control, and/or arrest situations
no driving a vehicle
no operating machinery or equipment
no working alone
no use of firearms
no typing, keyboarding, or entering data for more than hours each day
no use of a CRT or computer monitor for more than hours each day
no use, including repetitive, of (extremity/joint)
no weight bearing on (extremity)
Other restrictions (specify):
Based on my personal evaluation of the patient’s condition, the above information is accurate and complete.
Signature of Health Care Provider