Fitness-for-Duty Evaluation Report

Confidential fitness-for-duty evaluation prepared for third-party referral; distribution limited to authorized recipients.

Header

Examinee: [Full name] | DOB: [YYYY-MM-DD] | Employee ID: [If provided] | Job Title/Department: [Title / Department]
Referral Source: [Organization name] | Referring decision-maker: [Name, Title] | Referral date: [YYYY-MM-DD] | Referral reason: [return-to-work / safety concern / post-incident / periodic reassessment / other: specify]
Evaluator: [Name], [Credentials] | License: [State, Number] | Facility: [Facility name] | Contact: [Phone / Email]
Encounter: [YYYY-MM-DD] | Location: [Clinic/Facility] | Method: [in-person / telehealth] | Interpreter: [Present: language / Not present] | Chaperone: [Present / Not present]

Executive Summary

• Fitness determination: [Fit for duty / Fit for duty with restrictions / Temporarily unfit for duty / Unfit for duty for current position / Unable to determine] effective [YYYY-MM-DD]
• Essential-function capability: [Concise summary of capacity for core duties]
• Restrictions: [Specific measurable limits with duration, e.g., "No lifting >20 lb for 4 weeks"; "No safety-sensitive duty until clearance"]
• Re-evaluation: [Date or trigger for reassessment, if applicable]
• Rationale: [One sentence linking functional limits to job demands and safety risk]

Referral Question, Scope, and Consent

Referral Question: "[Verbatim referrer question]" — Restated as: [Clinician-restated question(s) focusing on essential functions, safety, and specific clearances]

Scope: [What will be addressed] | [What will not be addressed] | Standard applied: [ability to perform essential functions / direct-threat analysis / clearance for specific duty: driving / respirator / weapons / other]

Client and Role Clarification: [Identify client, typically employer]. This is an independent FFD evaluation; not a treating relationship.

Limits of Confidentiality: Will disclose functional conclusions, restrictions, and fitness determination to referral source. Will not disclose unrelated diagnoses or clinical details unless authorized or required by law.

Authorizations Obtained: [Releases signed for: records, collateral contacts, drug/alcohol testing data]. (If consent refused or partial, document what was requested, what was declined, and impact on evaluation.)

[Examinee questions answered; consent affirmed / Consent not affirmed: outcome and whether evaluation proceeded]

Sources of Information

• Examinee interview: [Date; duration in minutes]
• Records reviewed: [Job description, date/source] | [HR referral memo, date] | [Incident report, date] | [Treating clinician notes, dates] | [Imaging/labs, test and date] | [Prior FFD reports, dates] | [Medication list, date] (Mark items as "Not provided" / "Unavailable" / "Pending" if applicable.)
• Collateral contacts: [Names/Titles; dates]
• Tests administered: [Functional tests] | [Psychometric/cognitive tests] | [Validity/effort measures]

(If material data are missing, state what is missing and how this limits conclusions.)

Job Demands and Essential Functions

Role definition: [Job title] | [Shift pattern] | [Overtime/on-call expectations]

Essential vs. marginal duties: [Concise delineation]

Physical demands: [Lifting/carrying weights and frequency] | [Postures] | [Climbing] | [Fine motor/repetitive motion] | [Prolonged standing/walking/sitting]

Cognitive/psychological demands: [Sustained attention] | [Judgment/decision-making under pressure] | [Emotional regulation/confrontation management] | [Vehicle/weapons/critical equipment operation]

Environmental demands: [Heat/cold] | [Noise] | [Respiratory hazards/respirator use] | [Confined spaces/heights] | [Chemical exposures]

Safety-sensitive tasks: [Tasks where impairment could cause serious harm]

(If job demands not provided, state "Job demands not provided" and describe resulting limitations on the evaluation. Do not infer demands.)

Task	Essential?	Frequency	Consequence of Failure
[Task description]	[Yes / No]	[Rare / Occasional / Frequent / Constant]	[Safety/operational impact]

Medical and Psychological History

Presenting concern chronology: [Onset] | [Course] | [Triggers] | [Treatment to date] | [Response] | [Current status]

Functional impact: [Work and non-work tasks limited and how]

Relevant past history: [Prior similar episodes] | [Prior restrictions/accommodations] | [Prior work injuries] | [Hospitalizations relevant to safety risk]

Current medications: [Name/dose/frequency; recent changes; adherence; side effects relevant to duty performance including sedating or cognitively impairing effects]

Substance use: [Alcohol/cannabis/other] (Include only if job-relevant and within scope.)

Pertinent occupational history: [Prior roles] | [Exposure history] | [Prior accommodations]

Pertinent review of systems: [Neuro] | [MSK] | [Cardiopulmonary] | [Sleep] | [Cognition/mood] (Job-relevant pertinent positives and negatives only.)

Examination and Functional Assessment

Vitals

[BP, HR, RR, SpO2, Weight/Height/BMI] (Include if relevant to safety-sensitive work or exertional demands.)

Focused Physical Exam

• Neurologic: [Objective findings]
• Musculoskeletal: [ROM in degrees; strength grades; provocative tests]
• Cardiopulmonary: [Findings] (If exertion or respirator use is relevant.)

Mental Status Exam

[Appearance/behavior, speech, mood/affect, thought process/content, perception, cognition/orientation/attention/memory, insight/judgment] (Include only if cognitive or behavioral fitness is at issue.)

Functional Testing

• Lift/carry: [Weights, reps, technique, symptom response]
• Push/pull: [Forces achieved]
• Mobility: [Stairs/ramp/ladder, kneel/squat/reach/overhead]
• Gait/balance/endurance: [Walk test, timed up-and-go, etc.]
• Cognitive screening: [Results] (If applicable.)
• Effort/validity: [Observations and formal measures]
• Test conditions: [PPE used, initial pain level, rest breaks, observed symptom behavior]

(If test not completed, document why, stopping point, and whether limitation appeared physiologic, pain-limited, safety-limited, or uncertain.)

Diagnostic Data Reviewed

[Key imaging/lab/consultant results with dates; note if final or pending] (Include only findings with functional implications.)

Functional Capacity Synthesis

Essential Function	Demand Level	Current Capacity	Restriction or Accommodation	Evidence/Rationale
[Function]	[Quantified demand]	[Able without restriction / Able with restriction / Not able currently / Indeterminate]	[Measurable restriction or accommodation]	[Link to exam, testing, records]

Safety/Risk Analysis: [Specific hazard scenarios, e.g., loss of consciousness while driving, impaired judgment in confrontational encounters] | [Severity and likelihood in job context] | [Mitigations: restrictions, treatment stabilization, task removal] | [Residual risk assessment] (Include when safety is a core referral question. Use calibrated language when data are incomplete.)

Clinical Impressions

[Working diagnosis(es) to the extent necessary to explain functional limits and prognosis] | [If diagnostic uncertainty affects conclusions, note differential and implications] | [Link impairing symptoms to functional effects] (Minimize diagnoses that do not affect work capacity or safety.)

Fitness Determination

Determination: [Fit for duty / Fit for duty with restrictions / Temporarily unfit for duty / Unfit for duty for current position / Unable to determine]

Effective Date: [YYYY-MM-DD]

Restrictions:

• [Specific measurable restriction]

Duration: [Anticipated duration or end date; or "until re-evaluation"]

Re-evaluation: [Timeframe and triggers for reassessment]

(If "Unable to determine," list specific missing inputs and whether interim restrictions are advised.)

Recommendations

Work Recommendations:

• [Task exclusions/safety-sensitive duty limits]
• [Schedule limitations]
• [PPE/respirator limitations]
• [Environmental restrictions]

Clinical Recommendations:

• [Follow up with treating clinician]
• [Further diagnostics/rehabilitation/specialist referral]
• [Medication review for safety/side effects]

Limitations and Assumptions

• [Missing or incomplete job description/demands]
• [Missing treating records or incomplete collateral information]
• [Test validity/effort concerns]
• [Time constraints, single-visit or telehealth limitations]

[Statement on whether these limitations materially affect the determination]

Distribution and Attestation

Authorized Recipients: [Names/titles or departments authorized to receive this report]

Examinee Notification: [Examinee received explanation and/or copy: Yes / No; method and date]

Urgent Safety Communication: [If urgent concerns arose: who was notified, when (YYYY-MM-DD HH:MM), and what minimal necessary facts were conveyed]

Attestation:

Evaluator Signature: ___________________________ Date/Time: [YYYY-MM-DD HH:MM]

[Printed Name], [Credentials] — Independent fitness-for-duty evaluator

This report reflects information available at the time of evaluation and may require revision if new material data emerge.