Return to work form (fitness for duty)

Clear an employee to come back after illness or injury with a fitness-for-duty release: work status, any restrictions and how long they last, and the return date, with no diagnosis.

Use this template

Preview · answers aren’t saved

Page 1 of 2

Your name (required)

Job title (required)

Department

First day of leave (required)

Type of leave (required)

Job description

Optional. Helps your provider judge the essential duties. HR can attach it instead.

Click or drop a file here

PDF, Word, images · up to 10 MB

How will your provider give the release? (required)

21 questions · about 5 min · logic · file upload · signature

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Print it as a PDF Word version

Change the questions in Word, then print.

What you get back

Every response lands in your results the moment it is sent. Turn on email notifications and each one arrives like this, and the same answers become a row in your spreadsheet.

From PulseFormCreator

Subject New response to Return to work release

Your name: Tomasz Nowak
Job title: Delivery driver
Department: Logistics
First day of leave: 27 Jul 2026
Type of leave: Own illness or injury
How will your provider give the release?: My provider fills in the next section

and 10 more answers

A sample email with made-up answers.

submitted_at	Your name	Job title	Department	First day of leave	Type of leave
23 Sep 2026 09:41	Tomasz Nowak	Delivery driver	Logistics	27 Jul 2026	Own illness or injury

Export to CSV or Excel, or send responses to Google Sheets, Notion, Airtable, Slack or a webhook. All free.

What happens after someone submits

Medical details should reach HR and nobody else, and the review date should not depend on anyone’s memory.

Submitted
A release arrives

HR gets an email with a PDF of the release attached, for the medical file kept apart from the personnel file.
The provider has not released them

A second email goes to HR only for “Not yet released”, so the leave can be extended in time.
The restrictions have an end date

You get a calendar invite for the “Restrictions apply until” date, so the review is not missed.

Set this up when you use the template

What this form asks, and why

The last column shows how often real return to work forms ask for it.

Question	Why it is there	Real forms
Your name Required	Whose release this is, asked on 22 of 23 forms.	22 of 23 forms
Job title Required	The provider judges fitness against this job.	12 of 23 forms
Department	Optional. Routes the release to the right HR contact.	8 of 23 forms
First day of leave Required	Defines the leave the release covers.	12 of 23 forms
Type of leave Required	An injury at work brings a claim number with it.	5 of 23 forms
Workers’ compensation claim number Only when “Type of leave” is “Injury at work”	Shown only for an injury at work, so the release joins the claim.	1 of 23 forms
Job description	Optional. Lets the provider judge the essential duties; 3 of 23 forms attach one.	3 of 23 forms
How will your provider give the release? Required	Many providers have their own release. Either way counts.	Our own recommendation
Your provider’s signed release Required Only when “How will your provider give the release?” is “I will upload my provider’s own signed release”	Shown instead of the provider section.	Our own recommendation
Work status Required	The decision HR acts on, in the three options 10 of 23 forms use.	10 of 23 forms
Date the employee can return, or is expected to Required	Asked on 18 of 23 forms.	18 of 23 forms
Can the employee perform the essential functions of their job? Required Only when “Work status” is not “Not yet released”	The fitness-for-duty question. Hidden when not yet released.	7 of 23 forms
Restrictions Required Only when “Work status” is “Released with restrictions”	Shown only for a release with restrictions.	11 of 23 forms
The restrictions are Required Only when “Work status” is “Released with restrictions”	Tells HR whether to plan a review or a lasting change.	6 of 23 forms
Restrictions apply until Required Only when “Work status” is “Released with restrictions” and “The restrictions are” is “Temporary”	The date to check again.	6 of 23 forms
Next appointment or review date	Optional: when the release will be updated.	6 of 23 forms
Could any medication affect safety at work, such as driving or using machinery?	Matters for driving and machinery. It asks about the effect, not the medicine.	6 of 23 forms
Provider’s name and practice Required	So HR can check the release is real.	10 of 23 forms
Provider’s phone number Required	The number HR calls to verify it.	10 of 23 forms
Provider’s signature Required	Standard on US forms.	15 of 23 forms
Employee’s signature	Optional: the employee has seen what the provider wrote.	9 of 23 forms

What we left out

Diagnosis. 6 of 23 forms ask. HR can act on work status and restrictions alone, and PulseFormCreator is not HIPAA compliant.
An hours-per-activity grid. 5 of 23 forms grid hours standing or sitting and weights lifted. One restrictions box and the job description cover the same ground on a phone.
A general health-information consent. On 3 of 23 forms. The employee chooses what the provider sends, and the note says what not to.

What 23 real return to work forms ask

How many include each field, from forms organizations use today. Part of the Form Field Index.

The employee's name 22 of 23
Date the employee can or did return 18 of 23
Health care provider's signature 15 of 23
First day of absence or date leave began 12 of 23
Job title or position 12 of 23
Work restrictions 11 of 23
Full duty, restricted or not released 10 of 23
Provider’s name and contact 10 of 23

Read September 2026 · US 15, UK 7, Ireland 1 · Sources

Winston-Salem State University · university, US
Oregon Department of Administrative Services, Risk Management · state agency, US
City of Trenton, Ohio · city government, US
University of California · university system, US
Michigan Technological University · university, US
Oregon Institute of Technology · university, US
CSUSM Corporation (Cal State San Marcos auxiliary) · university auxiliary, US
Cape Fear Community College · community college, US
The University of Kansas Health System · hospital system (employee health), US
Maryland Department of Budget and Management · state agency, US
Alfred University · university, US
City and County of San Francisco, Department of Human Resources · city and county government, US
University of North Carolina at Charlotte · university, US
Baylor University · university, US
York College, The City University of New York · college, US
NHS North Yorkshire Clinical Commissioning Group · NHS body, UK
Dover District Council · local council, UK
University of Reading · university, UK
North Lanarkshire Council · local council, UK
The Shrewsbury and Telford Hospital NHS Trust · NHS trust (hospital), UK
Trinity College Dublin · university, Ireland
Cardiff and Vale University Health Board · NHS health board, UK
Ebor Academy Trust · multi-academy trust (schools), UK

How the form changes as people answer

Most people see a shorter form. These questions and screens only appear when an answer calls for them.

When “Type of leave” is “Injury at work”

shows “Workers’ compensation claim number”
When “How will your provider give the release?” is “I will upload my provider’s own signed release”

shows “Your provider’s signed release”
When “How will your provider give the release?” is “My provider fills in the next section”

shows “Health care provider’s release”
When “Work status” is not “Not yet released”

shows “Can the employee perform the essential functions of their job?”
When “Work status” is “Released with restrictions”

shows “Restrictions” and “The restrictions are”
When “Work status” is “Released with restrictions” and “The restrictions are” is “Temporary”

shows “Restrictions apply until”
When “Work status” is “Not yet released”

shows the “Not cleared to return yet” ending

Make it yours

Keep the link private

Turn on Password protection in Settings → Access and limits before you send the link.
Let the employee finish at the appointment

Save respondents’ progress on their device (Settings → Responses) is on, so the provider’s part can wait for the visit.
Say what happens if they are not cleared

Edit the “Not cleared to return yet” thank-you screen to name your HR contact.

Good practice and the law

This is general information, not legal advice. Rules differ by country and state, so check anything important where you operate.

US
Return-to-work questions must stick to whether the employee can do the job, and the answers stay a confidential medical record, so this release asks for work status and restrictions, never the condition. EEOC, disability-related inquiries
UK
Up to seven days off needs no fit note; after seven days in a row the employee must give one. GOV.UK, taking sick leave
UK
The law does not require a return-to-work meeting, but Acas recommends one. Acas, returning to work

Questions about this template

How do I record a phased return?

The provider picks “Released with restrictions”, writes the stages under Restrictions (four-hour days in week one, say), and sets “Restrictions apply until” to the plan’s last day. The review date is when the next release is due. New hours go on an employee availability form.

Can the provider use their own release form?

Yes. The employee uploads it instead, as long as it shows the return date, any restrictions and a signature.

How does the provider complete the fitness-for-duty release?

The employee opens the link at the appointment and hands over the phone, or prints the PDF and uploads the signed page.

Is there a version for a UK return-to-work meeting?

Pick “Return-to-work interview” above the preview. UK and Irish forms have no provider section: the manager records the meeting, the fit note, support, agreed actions and trigger points.

Which form do you need?

Not quite the job? One of these may fit, or browse all HR and employee forms.

Sick day report
For recording the absence when it happens, before anyone is cleared to return.
Accident report form
For recording the accident behind a work injury.
Separation record
When leave ends in “Unable to return after leave”.

Start with the return to work form template

Open it in the editor, name HR in the note at the top, and send the link before the appointment.