{{company_name}}
{{company_address}}
Phone: {{phone}} | Email: {{email}} | Web: {{website}}
Fitness for Duty Certificate
Complete all sections of this fitness for duty certificate in BLOCK CAPITALS. Incomplete forms cannot be processed.
Employee Details
| Field | Detail |
|---|---|
| Full Name | {{employee_name}} |
| Employee ID | {{employee_id}} |
| Job Title | {{job_title}} |
| Department | {{department}} |
| Manager | {{manager_name}} |
| Date | {{current_date}} |
Request / Information
| Field | Detail |
|---|---|
| Subject | Fitness for Duty Certificate |
| Effective Date | {{effective_date}} |
| Reason / Description | |
| Supporting Documents Attached | Yes / No |
| Additional Notes |
Declaration
I confirm that the information provided in this form is true, complete, and accurate to the best of my knowledge. I understand that providing false information may result in disciplinary action.
Manager Review
| Field | Detail |
|---|---|
| Manager Comments | |
| Recommendation | Approve / Decline / Refer to HR |
| Manager Name | {{manager_name}} |
| Date | {{current_date}} |
HR Action
| Field | Detail |
|---|---|
| Action Taken | |
| Processed By | |
| Date Processed |
Acknowledgement & Signatures
By signing below, both parties confirm they have read, understood, and agreed to the terms of this document.
Scope
Applies to all employees, contractors, and visitors of {{company_name}} while at Company premises or engaged in Company business.
Definitions
- "Occupational Health" means health risks arising from or related to work.
- "Reasonable Accommodation" means any modification to enable performance of essential duties.
- "Health Information" means medical, fitness-for-work, and related personal data.
Roles & Responsibilities
| Role | Responsibility |
|---|---|
| Executive Sponsor | Owns occupational health strategy and resourcing. |
| HR / Health Officer | Coordinates assessments, accommodations, and record keeping. |
| Line Manager | Identifies risks, supports return-to-work, escalates concerns. |
| Employee | Discloses fitness-for-work matters, follows medical advice, uses PPE. |
Risk Categories & Controls
| Risk | Mitigation | Owner |
|---|---|---|
| Workstation ergonomics | DSE assessment and adjustments | HR / Facilities |
| Mental health / burnout | EAP, workload reviews, manager training | HR |
| Infectious disease | Hygiene controls, isolation guidance | Health Officer |
| Physical hazards | PPE, training, incident reporting | Operations |
Incident & Injury Reporting
Confidentiality of Health Data
Health information is processed only on a legitimate basis under applicable data protection law. Access is restricted to authorized health and HR personnel, and disclosure to managers is limited to fitness-for-work conclusions.
Document Control
| Field | Value |
|---|---|
| Document Owner | Human Resources — {{company_name}} |
| Category | Health & Medical |
| Version | 1.0 |
| Effective Date | {{date}} |
| Next Review | Annually from effective date |
| Approved By | {{manager_name}} |
| Classification | Internal — Confidential |
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