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It is the practice of the Linn-Mar Community School District to require a fitness-for-duty certificate from their physician if an employee has been absent for one calendar week or more due to the employee's personal injury or illness, prior to reporting back to work.
Please see the attached job description to determine return to full duties or restrictions as necessary.
[Enter employee's name] may return to duties without restrictions on [Enter date].
OR
Due to illness/injury on [Enter date], this employee is not capable of performing the essential functions of their job.
Please indicate any restrictions below and the duration of the restrictions: [Be specific in the details]
Comments:
Anticipated date employee can return to full unrestricted duty: [Enter date]
Physician's Printed Name:
Physician's Signature:
Date Signed:
Business Address:
Business Phone:
Please return this form to:
Linn-Mar Community School District
Human Resources Office
3556 Winslow Road, Marion, IA 52302
Phone: 319-447-3053
Fax: 319-403-8008
Revised: 9/14; 3/17; 4/20; 4/23; 8/23
Related Policy: 403.7; 403.7-R1-R2; 403.7-E1-E7; E9