Fitness for Duty Questionnaire

This information is needed from supervisors in order to consider processing a formal “Fitness for Duty” request to Campus HR.

1. A “listing” of supervisor observations (to include the duration of such observations) which leads the supervisor to question the employees “Fitness for Duty”.
2. What essential duties and/or tasks does the individivual and/or their physician (supported by medical documentation) state the employee is unable to perform; if applicable?
3. What request(s) have been made by the “employee” for accommodation e.g. frequent breaks, etc.; if applicable?
4. The pattern of absence due to medical reasons should be detailed as follows:
   In the last (#) of months (indicate periods and/or specific dates), (name) attendance record reflects that of the (#) of available work hours in that period (excluding holidays, approved leave) he/she has been absent approximately (#) hours, or (#) % of the work hours scheduled, primarily due to medical reasons.  
   Provide other specifics which describe the impact of the absences on the business operation.
5. Copies of all medical documentation received from the employee as related to a(any) diagnosed medical condition as well as those that indicate the employee was under medical care for any period of time without specific diagnosis described.
6. What behavior/attitudinal factors have been “directly” observed by the supervisor(s) with regard to the employee in terms of their ability to perform the essential functions of their duties?
7. Listing of any questions that might be posed to a medical provider that would allow a proper evaluation of whether the employee is able to perform the essential duties of their position, with or without accommodation.