Form NPD-81 "Fmla Medical Release" - Nevada

What Is Form NPD-81?

This is a legal form that was released by the Nevada Department of Administration - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the Nevada Department of Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form NPD-81 by clicking the link below or browse more documents and templates provided by the Nevada Department of Administration.

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Download Form NPD-81 "Fmla Medical Release" - Nevada

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Family & Medical Leave Act (FMLA)
Medical Release
PART I-To be completed by employee
Name of employee (please print or type):
Date leave commenced:
Employee’s signature:
Date:
PART II-To be completed by health care provider
Date examined:
Effective as of ____________________ the above-named employee is:
____ Released to work without restrictions; or
____ Able to perform all essential functions (see attached description of essential job functions); or
____ Released to work with restrictions until _____________________ or _____ permanently:
Please describe any restrictions as they relate to the attached description of essential job functions:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Health Care Provider’s Signature:
Date:
Health Care Provider’s name (please print):
Type of practice/medical specialty:
Address:
Phone Number:
Fax Number:
GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA
Title II from requesting or requiring genetic information of an individual or family member of the individual, except as
specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when
responding to this request for medical information. ‘Genetic information’ as defined by GINA, includes an individual’s
family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual
or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive
reproductive services.
FMLA Medical Release
NPD-81
Page 1 of 1
Rev. 7/15
Family & Medical Leave Act (FMLA)
Medical Release
PART I-To be completed by employee
Name of employee (please print or type):
Date leave commenced:
Employee’s signature:
Date:
PART II-To be completed by health care provider
Date examined:
Effective as of ____________________ the above-named employee is:
____ Released to work without restrictions; or
____ Able to perform all essential functions (see attached description of essential job functions); or
____ Released to work with restrictions until _____________________ or _____ permanently:
Please describe any restrictions as they relate to the attached description of essential job functions:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Health Care Provider’s Signature:
Date:
Health Care Provider’s name (please print):
Type of practice/medical specialty:
Address:
Phone Number:
Fax Number:
GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA
Title II from requesting or requiring genetic information of an individual or family member of the individual, except as
specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when
responding to this request for medical information. ‘Genetic information’ as defined by GINA, includes an individual’s
family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual
or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive
reproductive services.
FMLA Medical Release
NPD-81
Page 1 of 1
Rev. 7/15