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2. Name*
3. Email Address*
5. Contact Phone Number*
6. Department*
7. Supervisor's Name*
9. This acknowledges that I am prepared to return to work from my FMLA Leave on:*
   This acknowledges that I am prepared to return to work from my FMLA Leave on:
11. Health Care Provider's Statement
    Health Care Provider's Statement
    This is to certify that the above named individual may return to work on the date indicated above.
13. Restrictions are as follows:

    1. No work restrictions
    2. Light Duty restrictions (explain below)
    3. Accommodations Required (explain below)
15. Explain any light duty restrictions or accommodations that are required, as well as ending date of restrictions, if known.
17. Signature of Health Care Provider
18. Date
20. Printed Name of Health Care Provider
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit Submit and Print

* indicates a required field