"Medical Certification - Release to Return to Work Form" - Northshore, Washington

This "Medical Certification - Release to Return to Work Form" is a document issued by the Northshore Fire Department specifically for Washington residents with its latest version released on September 1, 2014.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Northshore Fire Department.

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Download "Medical Certification - Release to Return to Work Form" - Northshore, Washington

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st
7220 NE 181
ST
Kenmore, WA 98028
Medical Certification – Release to Return to Work Form
PH: (425) 354-1775
Fax form to: HR,
To be completed by Health Care Provider (HCP) for Non-Work Related Illness/Injury:
PLEASE PRINT LEGIBLY
(425) 354-1781
Employee Name:
Employee’s Position**:
Visit Date:
____ / _____ / ______
Hrs/shift: ____ Days/week: _____
Work schedule before leave occurred:
Check one:
___ Days
___24hr shift
Certification (to be completed by treating HCP):
The above listed employee has been examined and/or treated for a medical illness or injury that prevented them from
____ / _____ / ______ to ____ / _____ / ______
working from (date):
____/______/______ ->
Released to Full Duty (without restrictions) on:
SIGN SECTION 5 & FAX FORM TO (425) 354-1781
Released to perform modified duty, if available, from (date):
(3a) Key Objective Finding(s):
____ / _____ / ______ through ____ / _____ / ______
Describe medical facts/condition
which support restrictive release:
No restrictions to HOURS OR max HOURS per shift: _____
No restrictions to DAYS per week OR max DAYS per week: _____
: ______/______/______
Date of the next appointment or review of restrictions
Complete the Key Objective Findings Box (3a) and estimate physical capacities (Section 4)
____ / ____ / ____
___ / ____ / ___
Not released to any work from:
to
Prognosis poor for return to work in current position at any date.
May need assistance returning to work.
If employee can perform the job functions only with an accommodation, indicate what
accommodation is required in Key Objective Findings box (3a).
->
SIGN SECTION 5 & FAX FORM TO (425) 354-1781
List essential functions employee is
Temporary Restrictions
Permanent Restrictions
unable to perform and/or additional
Seldom
Constant
Employee can (related to
restrictions:
Never
Occasional
Frequent
Up to
67-100%
medical leave condition):
0% of
11-33%
34-66%
10%
No
shift
1-3 hours
3-6 hours
(Blank space = Not Restricted)
0-1 hour
restrictions
Sit
Stand / Walk
Climb (ladder, stairs, etc.)
Twist
Bend / Stoop
Squat / Kneel
Please list any additional co morbid
Crawl
conditions (including medication) that
Reach
Left, Right, Both
require consideration when returning
to work and/or impact ability to
Work above shoulders L, R, B
complete essential job functions.
Work below shoulders L, R, B
Please explain:
Keyboard
L, R, B
Wrist (flexion/extension) L, R, B
Grasp (forceful)
L, R, B
Operate foot controls
L, R, B
Vibratory tasks; high impact
Vibratory tasks; low impact
Repetitive Motion Task:
Body Part:
Rotation of Head/Neck
Psychological/Cognitive Demands:
Sensory Demands: Hear/See/Talk
Comments:
Lifting / Pushing
Never
Seldom
Occas.
Frequent
Constant
If applicable:
Example
50 lbs
20 lbs
10 lbs
0 lbs
0 lbs
Next follow-up visit:
Lift
L, R, B
_____lbs
_____lbs
_____lbs
_____lbs
_____lbs
___ / ___ / ___
Carry
L, R, B
_____lbs
_____lbs
_____lbs
_____lbs
_____lbs
Push/Pull L, R, B
_____lbs
_____lbs
_____lbs
_____lbs
_____lbs
Completed by Physician (print name): ______________________________________
Date: ____/______/________
Signature: __________________________________
Type of Practice: ____________________________________
__________________________________________________________________________
Address of Provider:
PH: (
) ________ - _____________
FAX: (
) ________ - _____________
st
7220 NE 181
ST
Kenmore, WA 98028
Medical Certification – Release to Return to Work Form
PH: (425) 354-1775
Fax form to: HR,
To be completed by Health Care Provider (HCP) for Non-Work Related Illness/Injury:
PLEASE PRINT LEGIBLY
(425) 354-1781
Employee Name:
Employee’s Position**:
Visit Date:
____ / _____ / ______
Hrs/shift: ____ Days/week: _____
Work schedule before leave occurred:
Check one:
___ Days
___24hr shift
Certification (to be completed by treating HCP):
The above listed employee has been examined and/or treated for a medical illness or injury that prevented them from
____ / _____ / ______ to ____ / _____ / ______
working from (date):
____/______/______ ->
Released to Full Duty (without restrictions) on:
SIGN SECTION 5 & FAX FORM TO (425) 354-1781
Released to perform modified duty, if available, from (date):
(3a) Key Objective Finding(s):
____ / _____ / ______ through ____ / _____ / ______
Describe medical facts/condition
which support restrictive release:
No restrictions to HOURS OR max HOURS per shift: _____
No restrictions to DAYS per week OR max DAYS per week: _____
: ______/______/______
Date of the next appointment or review of restrictions
Complete the Key Objective Findings Box (3a) and estimate physical capacities (Section 4)
____ / ____ / ____
___ / ____ / ___
Not released to any work from:
to
Prognosis poor for return to work in current position at any date.
May need assistance returning to work.
If employee can perform the job functions only with an accommodation, indicate what
accommodation is required in Key Objective Findings box (3a).
->
SIGN SECTION 5 & FAX FORM TO (425) 354-1781
List essential functions employee is
Temporary Restrictions
Permanent Restrictions
unable to perform and/or additional
Seldom
Constant
Employee can (related to
restrictions:
Never
Occasional
Frequent
Up to
67-100%
medical leave condition):
0% of
11-33%
34-66%
10%
No
shift
1-3 hours
3-6 hours
(Blank space = Not Restricted)
0-1 hour
restrictions
Sit
Stand / Walk
Climb (ladder, stairs, etc.)
Twist
Bend / Stoop
Squat / Kneel
Please list any additional co morbid
Crawl
conditions (including medication) that
Reach
Left, Right, Both
require consideration when returning
to work and/or impact ability to
Work above shoulders L, R, B
complete essential job functions.
Work below shoulders L, R, B
Please explain:
Keyboard
L, R, B
Wrist (flexion/extension) L, R, B
Grasp (forceful)
L, R, B
Operate foot controls
L, R, B
Vibratory tasks; high impact
Vibratory tasks; low impact
Repetitive Motion Task:
Body Part:
Rotation of Head/Neck
Psychological/Cognitive Demands:
Sensory Demands: Hear/See/Talk
Comments:
Lifting / Pushing
Never
Seldom
Occas.
Frequent
Constant
If applicable:
Example
50 lbs
20 lbs
10 lbs
0 lbs
0 lbs
Next follow-up visit:
Lift
L, R, B
_____lbs
_____lbs
_____lbs
_____lbs
_____lbs
___ / ___ / ___
Carry
L, R, B
_____lbs
_____lbs
_____lbs
_____lbs
_____lbs
Push/Pull L, R, B
_____lbs
_____lbs
_____lbs
_____lbs
_____lbs
Completed by Physician (print name): ______________________________________
Date: ____/______/________
Signature: __________________________________
Type of Practice: ____________________________________
__________________________________________________________________________
Address of Provider:
PH: (
) ________ - _____________
FAX: (
) ________ - _____________
**The following is a list of essential job functions employees in a Firefighter, Lieutenant
or Battalion Chief position may be required to perform during active duty, per NFPA 1582
standards:
1. Performing fire-fighting tasks (e.g., hose line operations, extensive crawling, lifting and carrying
heavy objects, ventilating roofs or walls using power or hand tools, forcible entry), rescue
operations, and other emergency response actions under stressful conditions while wearing
personal protective ensembles (PPE) and self-contained breathing apparatus (SCBA), including
working in extremely hot or cold environments for prolonged time periods.
2. Wearing an SCBA, which includes a demand valve-type positive pressure facepiece or HEPA
filter masks, which requires the ability to tolerate increased respiratory workloads.
3. Exposure to toxic fumes, irritants, particulates, biological (infectious) and non-biological
hazards, and/or heated gases, despite the use of PPE including SCBA.
4. Depending on the local jurisdiction, climbing 6 or more flights of stairs while wearing fire
protective ensemble weighing at least 50lb or more and carrying equipment/tools weighing an
additional 20 to 40lb.
5. Wearing fire protective ensemble that is encapsulating and insulated. Wearing this clothing will
result in significant fluid loss that frequently progresses to clinical dehydration and can elevate
core temperature to levels exceeding 102.2°F (39°C).
6. Searching, finding, and rescue-dragging or carrying victims ranging from newborns up to adults
weighing over 200lb to safety despite hazardous conditions and low visibility.
7. Advancing water-filled hose lines up to 2.5 in. in diameter from fire apparatus to occupancy
(approximately 150 ft.); can involve negotiating multiple flights of stairs, ladders, and other
obstacles.
8. Climbing ladders, operating from heights, walking or crawling in the dark along narrow and
uneven surfaces, and operating in proximity to electrical power lines and/or other hazards.
9. Unpredictable emergency requirements for prolonged periods of extreme physical exertion
without benefit of warm-up, scheduled rest periods, meals, access to medication(s), or
hydration.
10. Operating fire apparatus or other vehicles in an emergency mode with emergency lights and
sirens.
11. Critical, time-sensitive, complex problem solving during physical exertion in stressful, hazardous
environments (including hot, dark, tightly enclosed spaces), further aggravated by fatigue,
flashing lights, sirens, and other distractions.
12. Ability to communicate (give and comprehend verbal orders) while wearing PPE and SCBA
under conditions of high background noise, poor visibility, and drenching from hose lines and/or
fixed protection systems (sprinklers).
13. Functioning as an integral component of a team, where sudden incapacitation of a member can
result in mission failure or in risk of injury or death to civilians or other team members (e.g., two
in, two out as described in NFPA 1500).
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,
Northshore Fire Department asks that the health care provider not provide any genetic information when responding to requests 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 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.
Rev. 9/14
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