Fitness-for-Duty Evaluation Report

Examinee: [Full name], [DOB], [Employee ID]
Position: [Job title], [Department], [Work location]
Referral Source: [Name], [Title], [Organization], [Referral date]
Evaluator: [Name], [Credentials], [License number and jurisdiction]
Evaluation Date(s): [Date(s), location(s), and modality: in-person / telehealth]
Report Date: [Date]
Distribution: [Recipients authorized to receive report]

(This is a forensic, non-treatment evaluation conducted for employment-related decision support. If a section heading applies but no data exist, retain the heading and document "Not obtained" or "Not available" with a brief explanation.)

1. Executive Summary

Referral Question(s): [Verbatim referral questions as provided by the referral source]

Methods: [Evaluation date(s) and duration]; [Key sources reviewed]; [Testing performed: yes / no]

Key Findings: [Job-relevant findings in functional terms tied to essential job demands]

Fitness Opinion: [Fit for Full Duty / Fit with Restrictions / Temporarily Unfit / Unfit for Duty]; [Timeframe if temporary] (Include basis for anticipated change if applicable.)

Restrictions or Conditions: [Duty restrictions, accommodations, or conditions / None]

Re-evaluation: [Recommended timeline and triggers for re-evaluation]

Rationale: [Brief statement linking opinion to specific evidence and job demands] (Cite converging evidence sources; avoid diagnostic labels unless necessary.)

2. Referral Context and Questions

Referral Context

[Reason for referral, triggering events, timeline, and observers/reporters] (Distinguish allegations from substantiated facts from examinee self-report. Identify what decisions the evaluation will inform and any constraints on disclosure.)

Referral Questions

• [Question 1 verbatim]
• [Question 2 verbatim]
• [Additional questions as provided verbatim]

Operational Definitions: [Definitions of key terms as used by the employer or applicable policy, e.g., "fit for duty," "essential functions," "direct threat"]

3. Authorization and Informed Consent

Client Identification: [Retaining entity: employer / agency / board] (Clarify that this is not a treatment relationship.)

Scope: [Statement that evaluation is limited to job-relevant psychological functioning and specific referral questions]

Consent Process: [Purpose explained]; [Procedures described]; [Recipients of results]; [Limits of confidentiality]; [Voluntary / Mandatory nature]; [Consequences of non-participation]; [Releases obtained]

Declined Components: [Components declined by examinee and impact on conclusions / None]

4. Sources and Methods

(List all sources reviewed with date ranges. State when a method was not used and why. Indicate when conclusions are based on multiple converging sources.)

• Referral documentation: [Documents reviewed]
• Job description or task analysis: [Document title and date / Not provided]
• Personnel records: [Types and date ranges reviewed]
• Medical/psychiatric records: [Types and date ranges reviewed]
• Prior evaluations or testing: [Types and dates]
• Collateral interviews: [Name, title, relationship, and date for each]
• Self-report measures and psychological tests: [Instruments administered]

Examination Procedures: [Interview duration and setting]; [MSE performed: yes / no]; [Testing administered: list instruments / none]; [Telehealth-specific details and limitations if applicable]

Methods Not Used: [Methods omitted and rationale, e.g., "No psychological testing was administered because..."]

5. Job Analysis and Essential Functions

Position Summary: [Core duties]; [Schedule demands]; [Work environment]; [Supervision level]; [Required interactions: public-facing / high-conflict / other]; [Safety-sensitive elements: weapons / driving / machinery / patient care / restraint authority / other]

(If a complete job description was not provided, note this limitation and identify alternative sources used.)

Essential Functions and Psychological Demands

Essential Function	Psychological Demands Required	Safety-Sensitive
[Function or task]	[Cognitive, emotional, interpersonal, and behavioral demands]	[Yes / No]
[Function or task]	[Demands]	[Yes / No]

6. Evaluation Findings

Behavioral Observations

[Objective observations: appearance, cooperation, rapport, speech characteristics, observable affect, psychomotor activity, consistency of presentation] (Note behavioral safety signals with direct quotes sparingly when clinically significant. If remote evaluation, note observational limitations.)

Relevant Background

[Presenting concerns and examinee's account of referral circumstances]; [Occupational history and performance]; [Psychiatric and medical history relevant to functioning]; [Substance use history if safety-sensitive or referral-related]; [Legal or violence history if risk-related] (Include only job-relevant information.)

Current Symptoms and Functioning

[Mood and anxiety symptoms]; [Cognitive complaints]; [Irritability and impulse control]; [Sleep and fatigue]; [Medication effects] (Describe functional impact on specific work tasks.)

Mental Status Examination

(If MSE was not performed, state "MSE not performed" and explain why, then omit the fields below.)

Appearance/Behavior: [Findings]

Speech: [Findings]

Mood/Affect: [Findings]

Thought Process/Content: [Findings]

Perceptions: [Findings]

Cognition: [Orientation, attention, memory findings]

Insight/Judgment: [Findings]

Impulse Control: [Findings]

Safety Assessment: [Suicidal ideation: present / denied]; [Homicidal ideation: present / denied]; [Intent, plan, means if applicable]; [Protective factors]

7. Collateral Information and Records

[For each collateral source: identity, relevance to referral questions, key observations about workplace behavior or performance, potential bias] (Identify concordance and discrepancies across self-report, records, and collateral data.)

(If collateral information was not obtained, state why and note resulting limitations on conclusions.)

8. Psychological Testing

(If no testing was administered, state "No psychological testing was administered" with rationale and omit the fields below.)

Instruments Administered: [Instrument names, dates, and modality]

Response Validity: [Engagement and effort]; [Response consistency]; [Over-reporting or under-reporting indicators] (If validity is compromised, specify what cannot be interpreted.)

Results: [Job-relevant interpretations tied to essential demands] (Present in functional terms rather than raw scores. Place technical details in appendix if needed.)

9. Functional Capacity Analysis

(This section links clinical data to job demands. For each relevant domain, document evidence, current capacity, and job implications. Mark domains as "unknown" if data insufficient, and specify what additional information would be needed.)

• Cognitive capacity (attention, memory, processing speed): [Evidence]; [Capacity: intact / limited / unknown]; [Job implications]
• Executive function and judgment: [Evidence]; [Capacity: intact / limited / unknown]; [Implications]
• Emotional regulation and stress tolerance: [Evidence]; [Capacity: intact / limited / unknown]; [Implications]
• Impulse control: [Evidence]; [Capacity: intact / limited / unknown]; [Implications]
• Interpersonal functioning and conflict management: [Evidence]; [Capacity: intact / limited / unknown]; [Implications]
• Reliability and rule adherence: [Evidence]; [Capacity: intact / limited / unknown]; [Implications]
• Performance under acute stress: [Evidence]; [Capacity: intact / limited / unknown]; [Implications]

Essential Functions Mapping

Essential Function or Task	Evidence Reviewed	Current Capacity	Limitations	Potential Mitigations
[Function or task]	[Key data points from records, interview, testing, collateral]	[Intact / Limited / Unknown]	[Specific functional limitations]	[Accommodations, restrictions, or supports]
[Function or task]	[Evidence]	[Intact / Limited / Unknown]	[Limitations]	[Mitigations]

Duration and Trajectory: [Expected duration and course if supported by evidence; if unknown, specify what additional data would clarify]

10. Risk and Safety Assessment

Risk Domains Evaluated: [Self-harm risk]; [Risk to others and workplace violence potential]; [Substance-related risk]; [Risk from impaired judgment due to psychiatric symptoms]; [Medication side effects affecting safety]

Risk Factors: [Acute factors]; [Chronic factors]; [Foreseeable workplace triggers]

Protective Factors: [Identified protective factors]

Direct-Threat Analysis: (Include when referral involves potential safety threat.) [Nature and severity of potential harm]; [Likelihood of occurrence]; [Imminence]; [Expected duration]; [Whether risk can be reduced to acceptable levels through restrictions, accommodations, or monitoring]; [Assumptions underlying this opinion]

11. Fitness Determination

Opinion

[Fit for Full Duty / Fit with Restrictions / Temporarily Unfit (with timeframe) / Unfit for Duty (permanent / indeterminate)]

Restrictions

[Specific duties to avoid, rationale tied to functional limitations, and duration / None indicated]

Accommodations

[Potential accommodations and purpose / None identified] (Feasibility determination is retained by employer.)

Conditions

[Conditions for return or continued duty: treatment adherence, monitoring, EAP participation]; [Method for verifying compliance]; [Triggers for re-evaluation / None]

Answers to Referral Questions

• [Question 1 verbatim]: [One-sentence opinion]. [Rationale citing specific evidence]. [Functional limitations if any]. [Risk statement if relevant]. [Timeframe and re-evaluation plan].
• [Question 2 verbatim]: [Structured answer as above].

(This report provides clinical-functional opinions to inform the employer's determination; the employer retains ultimate decision authority.)

12. Recommendations

(Omit this section entirely if no recommendations are warranted.)

To Employer/Agency

• [Duty modifications or restrictions]
• [Supervision or monitoring needs]
• [Safety planning or access limitations]
• [Documentation recommendations]

To Examinee

• [Treatment referrals or resources]
• [Follow-up care]
• [Safety resources if indicated]

Re-evaluation

[Recommended timeline]; [Triggers warranting earlier review]

13. Limitations

[Missing or incomplete records]; [Limited collateral cooperation]; [Contested or unverified facts]; [Examinee non-cooperation]; [Testing validity concerns]; [Telehealth limitations]; [Cultural or language considerations]; [Single-session assessment limitations]

(Use "cannot determine" rather than speculation. For disputed facts, provide conditional opinions: "If [fact] is substantiated, then..." Conclusions reflect information available as of the evaluation date(s).)

Signature

[Evaluator signature]
[Printed name, credentials]
[License number and jurisdiction]
[Date signed]
[Practice contact information]
[Supervisor co-signature if applicable]