Form OP-110218 Attachment A "Fmla Return to Work Medical Certification" - Oklahoma

What Is Form OP-110218 Attachment A?

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

Form Details:

  • Released on June 1, 2020;
  • The latest edition provided by the Oklahoma Department of Corrections;
  • 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 OP-110218 Attachment A by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Corrections.

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Download Form OP-110218 Attachment A "Fmla Return to Work Medical Certification" - Oklahoma

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Attachment A
OP-110218
Oklahoma Department of Corrections
FMLA Return to Work Medical Certification
Employees on FMLA leave due to the employee’s serious illness will not be permitted to return to
work unless their health care provider certifies that they are medically able to resume performing
essential job functions. Employees must provide this form to their health care provider and furnish
the completed form to their facility/unit.
The facility/unit must provide this form and a copy of the applicable job family descriptor to the
employee.
To be completed by the Employee:
I hereby authorize the Oklahoma Department of Corrections, director of Human Resources or
chief medical officer to contact the health care provider listed below to clarify or authenticate the
information below.
___________________________________________________ ________________________
Employee’s Signature
Date
To be completed by the Health Care Provider: (Please complete this form when the employee
is seeking your release to return to work)
Employee’s Name: _____________________________
SS#: __________________________
Date the condition began: _____________________
I certify that beginning ______/______/______ (date), the above named employee is able to
resume performing the functions of his/her job with or without reasonable accommodation.
If reasonable accommodation is requested, please provide the following information:
List all restriction/limitations that apply: _____________________________________________
Probable duration of restriction/limitations: ___________________________________________
Recommended accommodation(s) is/are as follows: ___________________________________
Date employee will be able to resume performing the functions of the job without restriction: ____
I have been provided and have reviewed the employee’s job family descriptor.
Yes
No
_________________________________________________/_______________
Health Care Provider Signature
Date
_____________________________________
________________________________
Printed Name
Type of Practice
_____________________________________
________________________________
Address
Phone
(R 06/20)
This completed form contains confidential medical information and must be maintained in the
employee’s medical file.
Attachment A
OP-110218
Oklahoma Department of Corrections
FMLA Return to Work Medical Certification
Employees on FMLA leave due to the employee’s serious illness will not be permitted to return to
work unless their health care provider certifies that they are medically able to resume performing
essential job functions. Employees must provide this form to their health care provider and furnish
the completed form to their facility/unit.
The facility/unit must provide this form and a copy of the applicable job family descriptor to the
employee.
To be completed by the Employee:
I hereby authorize the Oklahoma Department of Corrections, director of Human Resources or
chief medical officer to contact the health care provider listed below to clarify or authenticate the
information below.
___________________________________________________ ________________________
Employee’s Signature
Date
To be completed by the Health Care Provider: (Please complete this form when the employee
is seeking your release to return to work)
Employee’s Name: _____________________________
SS#: __________________________
Date the condition began: _____________________
I certify that beginning ______/______/______ (date), the above named employee is able to
resume performing the functions of his/her job with or without reasonable accommodation.
If reasonable accommodation is requested, please provide the following information:
List all restriction/limitations that apply: _____________________________________________
Probable duration of restriction/limitations: ___________________________________________
Recommended accommodation(s) is/are as follows: ___________________________________
Date employee will be able to resume performing the functions of the job without restriction: ____
I have been provided and have reviewed the employee’s job family descriptor.
Yes
No
_________________________________________________/_______________
Health Care Provider Signature
Date
_____________________________________
________________________________
Printed Name
Type of Practice
_____________________________________
________________________________
Address
Phone
(R 06/20)
This completed form contains confidential medical information and must be maintained in the
employee’s medical file.