Medical Certification

Employee Name:

People First ID:
Position Title:

Leave Requested for the Month of

I hereby authorize any physician examining me to release information recorded on the examination report and include any other pertinent facts regarding my condition. Verification information may also be released to my employer, the Department of Economic Opportunity.
Signature
Date
PHYSICIAN’S REPORT

"This section must be completed and signed by the attending physician only."

New form must be submitted for each calendar month for Sick Leave Pool/Donation usage.

Medical Diagnosis: __________________________________________________________________________________

Explanation of Diagnosis in Laymen’s Term: _____________________________________________________________

Would you consider this condition to be: (check one) ___ an injury, ___ an illness, ___result of an accident, ___ other (please explain)

___________________________________________________________________________________________________

What is the date you first examined the patient for this condition? _____________________________________________

Current prescribed treatment and dates: __________________________________________________________________

___________________________________________________________________________________________________

Provide the exact period of time (dates) for the current month that it is medically necessary for the patient to be excused from work. _________________________________________________________________________________________

6a.	Probable duration of absence: __________________________________________________________________________

Does this condition require the patient’s absence from work full time? _________________________________________

7a. If so, when will the patient be able to perform limited duties or work hours?______________________________________

Does this condition require the employee’s absence from work part time? Intermittently? __________________________

If so, provide the daily number of hours the employee is released to work. And the probable duration of the absence:

___________________________________________________________________________________________________

Physician Signature (Original Ink Signature is Required)	Date	Medical License Number

Type of Practice: _______________________________	Telephone Number: ___________________________________

Address: ______________________________________	City/State/Zip: _______________________________________

Patient has the following restrictions relating to this illness/injury:

NOTE: In terms of an 8 hour work day:	Occasionally = 0-33%, Frequently = 34-66%, Continuously = 67-100%

1. In an 8 hour workday, the patient can (circle # hours anticipated for each activity w/o interruptions):

# HOURS

A. Sit	0	1	2	3	4	5	6	7	8

B. Stand	0	1	2	3	4	5	6	7	8

C. Walk	0	1	2	3	4	5	6	7	8

D. Type	0	1	2	3	4	5	6	7	8

Patient can lift or carry:	Occasionally	Frequently	Continuously

A. Up to 10 lbs.	( )	( )	( )

B. 11 - 20 lbs.	( )	( )	( )

C. 21 - 50 lbs.	( )	( )	( )

D. 51 – 100 lbs.	( )	( )	( )

3. Patient is able to:

A. Bend	( )	( )	( )

B. Squat	( )	( )	( )

C. Kneel	( )	( )	( )

D. Crawl	( )	( )	( )

E. Climb ladders	( )	( )	( )

F. Climb stairs	( )	( )	( )

G. Reach above shoulder level	( )	( )	( )

The patient can use hand for repetitive action such as:

Dominant	Simple Grasping Pushing/Pulling	Fine Manipulating	Using PC

A. Right hand	Yes No	Yes No	Yes No	Yes No	Yes No

B. Left hand	Yes No	Yes No	Yes No	Yes No	Yes No

Are there any other restrictions which might impact the patient’s ability to do his/her job:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Is patient under treatment and/or medication that might affect his/her ability to work? Yes No

DEO Form HRM-53D (08/11)

State of Florida

HaywardN

2017-01-05

McGill, Jackie

Division of Safety