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THE UNIVERSITY OF NORTH CAROLINA AT CHARLOTTE
FITNESS FOR DUTY CERTIFICATION
(Required of all Employees returning from a Disability Leave of any kind.)
THIS FORM IS NOT COMPLETE WITHOUT A JOB DESCRIPTION LISTING
PHYSICAL REQUIREMENTS OF THE POSITION ATTACHED
| PART I: TO BE COMPLETED BY EMPLOYEE |
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| 1. NAME: |
2. POSITION: |
| 3. DATE LEAVE BEGINS
OR BEGAN: | 4. DATE PLANNED FOR RETURN TO WORK: |
| 5. EMPLOYEE SIGNATURE AND DATE |
| PART II: TO BE COMPLETED BY EMPLOYEE'S HEALTHCARE PROVIDER
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| 6. I certify that I have read the job description enclosed with this form and that the above-named employee is physically fit to meet the physical/mental requirements listed in the description with or without (please circle one) reasonable accommodation. If accommodation is required, please list specific limitations to activity in remarks section.
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| Provider' s Signature and Date: |
| 7. Healthcare Provider's |
8. Area of Practice/Specialty (if any)
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| Name: |
Address:
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| Phone: | |
| PART III: TO BE COMPLETED BY UNC CHARLOTTE, BENEFITS OFFICE
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9. REMARKS:
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| Please return this form to: |
UNC Charlotte |
FOR OFFICE USE ONLY |
| Benefits Office | |
| 9201 University City Blvd. |
Confirm Return Date:______________ |
| Charlotte, NC 28223 |
Notified Payroll on:_______________ |
| Phone (704) 547-4271 - FAX (704) 547-3239
| Initials ______________
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Routing: Department Supervisor |
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