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PHYSICIAN'S STATEMENT

_______________, WORKER

q

CAN perform the essential tasks of the job described on a reasonably continuous, full time basis as of_______________ (date).  (SAME JOB FULL TIME)

q

CAN perform the essential tasks of the job described on a reasonably continuous basis as of ____________ (date) according to the following schedule       (TRANSITIONAL RETURN TO WORK - TO SAME JOB):                                                Comments

Hours per day/workdays per week

Week 1:  _____hours/_____days

Week 2:  _____hours/_____days

Week 3:  _____hours/_____days

Week 4:  _____hours/_____days

q

CAN perform the essential tasks of the job described on a reasonably continuous basis with the following temporary  restrictions as of _______________    (date)

for _________________________.

(SAME JOB WITH TEMPORARY RESTRICTIONS OR MODIFICATIONS):

q

CAN perform the essential tasks of the job described on a reasonably continuous basis with the following job modifications only, as of __________________ (date):

(SAME JOB WITH PERMANENT RESTRICTIONS OR MODIFICATIONS):

q

CANNOT  q at this time   q ever   perform the essential tasks of the job described on a reasonably continuous basis for the following objective medical reasons:

COMMENTS:

_________________________________________________

PHYSICIAN’S SIGNATURE           DATE

________________________________

PHYSICIAN’S PRINTED NAME

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