Get Medical Form 3

Intent to Return and Fitness for Duty/Medical Release FMLA - Form 3 SECTION 1 Instructions for the DEPARTMENT A copy of the essential job functions and regular work schedule/hours must be attached. SECTION 2 To be completed by the EMPLOYEE Name of Employee Print Employee Contact Information phone email If leave was for a continuous block of time and my health care provider has released me to return to work I intend to return to work as scheduled. If no I am stating I do not intend to return to work and I am resigning my employment with Indiana University. o Yes o No I o authorize o do not authorize check one the health care provider identified below to provide the information requested on this form for the purposes of determining my fitness for duty and for a designated IU human resources professional to contact the health care provider to authenticate and/or clarify the information if needed* I understand that if I do not agree to this authorization my return to work may be delayed or denied* Employee s Signature Date An employee who fraudulently obtains FMLA leave will be subject to disciplinary action up to and including termination* Instructions to the Health Care Provider Please review the employee s work schedule and essential functions and answer the following Is employee able to perform the essential functions of the position that are attached o Yes o No If yes the employee is fully released to return to work on date If no the employee is released with restrictions to return to work on date. Please list the essential functions the employee is unable to perform until date or o permanently. Additional comments Health Care Provider Information GINA Notification to Health Care Providers 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 employees or their family members. In order to comply with this law we are 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. o Yes o No I o authorize o do not authorize check one the health care provider identified below to provide the information requested on this form for the purposes of determining my fitness for duty and for a designated IU human resources professional to contact the health care provider to authenticate and/or clarify the information if needed* I understand that if I do not agree to this authorization my return to work may be delayed or denied* Employee s Signature Date An employee who fraudulently obtains FMLA leave will be subject to disciplinary action up to and including termination* Instructions to the Health Care Provider Please review the employee s work schedule and essential functions and answer the following Is employee able to perform the essential functions of the position that are attached o Yes o No If yes the employee is fully released to return to work on date If no the employee is released with restrictions to return to work on date. Please list the essential functions the employee is unable to perform until date or o permanently. Additional comments Health Care Provider Information GINA Notification to Health Care Providers 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 employees or their family members.