Human Resources, CSQ, P.O. Box 3003, Lancaster, PA 17604-3003, Fax: (717) 358-3969

CONFIDENTIAL

Medical Leave

Return to Work Certification

Employee's (Patient’s) Name: Date of Birth:

Personal health information provided in conjunction with a leave of absence will be kept confidential.

I authorize the following health-related information to be released to Franklin & Marshall College for the purpose of determining my eligibility for return to work from medical leave. I understand the College may require a second medical opinion or independent medical evaluation, at its expense, before I return to work.

Employee’s Signature Date

To be completed by the employee's health care provider:

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, Franklin & Marshall College is asking that you not provide any “genetic information” when responding to this request 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’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.

1. Date patient was last seen in your office:

2. On what date was the employee / patient first unable to work?

3. On what date is the patient able to return to work without risk to self or others?

(over)

4. (For communicable illness only.) In your judgment, is the patient able to return to work on the date indicated above without risk of spreading the communicable illness to others?  Yes  No

As applicable, please provide a brief explanation to support your responses above:

5. In your judgment, is the patient able to return to work on the date indicated above and safely perform all his/her essential job functions, with or without a reasonable accommodation?  Yes  No (if no, please see #7)

As applicable, please provide a brief explanation to support your response above:

6. Please describe any accommodations necessary to allow the patient to perform his/her essential job duties, and expected duration:

7. If not able to perform all essential job functions, is the patient able to safely perform “light duty” work? If so, please describe applicable work restrictions and the expected duration:

Additional comments (if applicable):

Name of Physician or Health Care Practitioner (please print) Phone Number

Name and Address of Practice

Signature of Physician or Health Care Practitioner Date

Please return this completed form to Human Resources, Franklin & Marshall College, P.O. Box 3003, Lancaster, PA 17604-3003, or fax to (717) 358-3969.