Tip for N/A (employer-specific)

Get this form completed BEFORE your return date — do not wait until the last day

Tip for N/A (employer-specific)

Be specific about restrictions: 'No lifting over 10 lbs for 4 weeks' is better than 'light duty'

Tip for N/A (employer-specific)

If your employer cannot accommodate restrictions, discuss options including extended leave or reassignment

Employment / FMLAmoderateDoctor signature required

Return to Work / Fitness for Duty Certification

N/A (employer-specific) · Employers

Certification that employee can return to work, with or without restrictions. Documents functional capacity and any ongoing limitations or accommodations needed.

Form Details

Total fields: 25
Auto-fillable: 16 (64%)
Time without BeneFill: 20 minutes
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Time saved: 14 minutes
Filled by: doctor
Frequency: per incident

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Where to Submit This Form

📬

Return to your employer's HR department

Submit before your planned return-to-work date.

🏢

Hand-deliver to HR or your supervisor on your first day back

Required Attachments

📎 Must be completed and signed by your treating physician
📎 Clear statement of fitness for duty — either full duty or with specific restrictions
📎 If restrictions apply: type, duration, and any accommodations needed (e.g., 'No lifting over 10 lbs for 4 weeks')

Processing Time

Employer typically reviews within 1-3 business days.

What Happens Next

Your employer will review restrictions and determine if they can accommodate them. You may be assigned modified duties or a gradual return-to-work schedule.

Tips for This Form

✓ Get this form completed BEFORE your return date — do not wait until the last day
✓ Be specific about restrictions: 'No lifting over 10 lbs for 4 weeks' is better than 'light duty'
✓ If your employer cannot accommodate restrictions, discuss options including extended leave or reassignment
✓ Under FMLA, your employer can require a fitness-for-duty certification before you return from FMLA leave

More Employment / FMLA Forms

FMLA Certification - Employee's Serious Health Condition

WH-380-E · U.S. Department of Labor

Certification of Health Care Provider for Employee's Serious Health Condition. Medical certification for FMLA leave for the employee's own condition.

FMLA Certification - Family Member's Serious Health Condition

WH-380-F · U.S. Department of Labor

Certification of Health Care Provider for Family Member's Serious Health Condition. Medical certification when employee needs leave to care for a family member.

FMLA Notice of Eligibility and Rights & Responsibilities

WH-381 · U.S. Department of Labor

Notice of Eligibility and Rights & Responsibilities. Employer must provide within 5 business days of FMLA leave request, stating whether employee is eligible.

FMLA Designation Notice

WH-382 · U.S. Department of Labor

Designation Notice. Employer designates leave as FMLA-qualifying or denies it. Must be provided within 5 business days of receiving sufficient certification.

FMLA Certification - Qualifying Exigency (Military)

WH-384 · U.S. Department of Labor

Certification of Qualifying Exigency for Military Family Leave. For leave due to a covered family member's active duty or call to active duty.

FMLA Certification - Serious Injury/Illness of Servicemember

WH-385 · U.S. Department of Labor

Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (current servicemember).

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Employers or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.