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Patient/Employee Signature Date To be completed only by Physician Effective the above-named employee is certified as fit to resume work duties as follows:  FORMCHECKBOX  Full time duties, no restrictions  FORMCHECKBOX  Full time duties, with restrictions Able to perform all essential duties Released to work with restrictions (see attached description of essential job duties) (describe restrictions as they relate to the attached description of essential job duties):  FORMCHECKBOX  Part time duties, no restrictions  FORMCHECKBOX  Part time duties, with restrictions Able to perform all essential duties Released to work with restrictions (see attached description of essential job duties) (describe restrictions as they relate to the attached description of essential job duties): Additional comments, if any: Name of Health Care Provider: Telephone: Address: Type of practice/specialty: Signature: Date: This form may be completed and faxed to: ATTN: HUMAN RESOURCES, FMLA SHAWNEE STATE UNIVERSITY Fax: 740 351.3505 or Phone: 740 351.3420      FILENAME \p \* MERGEFORMAT Z:\Fmla\1 - FMLA - 2009--\4.FMLA TEMPLATE - Fit for duty certif.doc Upd 1.19.2011; 3.22.2010/LstPrtd:  DATE \@ "M.d.yyyy" \* MERGEFORMAT 6.23.2014 &(Jdhjl~ymZL6Z*jAhZlhu>*CJOJQJUhZlhu>*CJOJQJ$jhZlhu>*CJOJQJUhqhq>*OJQJhuOJQJhqh]OJQJhH?OJQJhqhF6OJQJht@CJOJQJht@ht@CJOJQJh2Y:CJ OJQJht@CJ OJQJhCJ OJQJmHnHuh2CJ OJQJmHnHu,jhhCJ OJQJUmHnHu(hjl b c d h $ $a$ $ 8@ $a$$ 8@ $a$gdn $ $da$$ ,4$a$gd $ $a$gdq $ $a$gdF $ $a$gd2 $ $a$gd   xfVH9.hqhFOJQJjhqhFOJQJUhqh]56OJQJhhq>*CJOJQJaJ"jhq&>*CJOJQJUaJ.jhBhhFV>*CJOJQJUaJhhFV>*CJOJQJaJ(jhhFV>*CJOJQJUaJhqh]>*OJQJhqh]OJQJh`'OJQJhu>*OJQJ$jhZlhu>*CJOJQJUjhq&>*CJOJQJU " $ : < X Z \ b ӲӦiWK=hqh]56OJQJhqhq>*OJQJ"jhq&>*CJOJQJUaJ.jChhFV>*CJOJQJUaJhhFV>*CJOJQJaJ(jhhFV>*CJOJQJUaJhqh]>*OJQJ#jPChqhtC-OJQJUjhqh]OJQJUhqh]OJQJjhqhFOJQJU#jBhqhIOJQJUb d e f g h    < = > L M N r s u Ǽvn\nPh`'h`'H*OJQJ#jDhqh!OJQJUh`'OJQJ#jPDhqh!OJQJUjhqh]OJQJUhqh]>*CJOJQJht@CJOJQJhqh]CJOJQJhqh]OJQJhqh]5>*CJOJQJhqh]CJH*OJQJhqh]>*CJOJQJhqh]CJOJQJ  s O R U X we$ h$d<a$gd $ h$d<a$gd $ h$d8<a$gd $ ,$d$a$gdL$ ,$d<a$gdL$ ,$<a$gd`'$  @a$$ $$dNa$ u O P Q S T V W X Y Z h i j 񭡭um[m#jEhqh!OJQJUh`'OJQJ#j8Ehqh!OJQJUjhqh]OJQJUhqh]OJQJh h >*OJQJh h]>*OJQJ hL^JhLhL^JhLh]H*OJQJ^JhLh`'H*OJQJ^JhLhLOJQJ^JhLhLH*OJQJ^JX  sssa$ 8P$a$gd`'$ 8$a$gd`' hd#8$<gd`'$ h$d<a$gd $ h$d8<a$gd $ ,$d$a$gdL$ ,$d<a$gdL$ ,$<a$gd`'   B C D "%24;=影tftftfXftftftfhrh2Y:>*CJOJQJhrh]>*CJOJQJhrh]CJOJQJh`'6CJOJQJhqh]CJOJQJhqh]OJQJhqh]CJOJQJh h >*OJQJh h]>*OJQJ hL^JhLhL^JhLhLOJQJ^JhLhLH*OJQJ^Jh`'hLH*OJQJ" &'=>? !H4$gdr !H$gdr !H$<$dN$@agdr $ 2 a$gdr$ 8P$a$$ 8P$da$=?h<=>?CNSUabɹznbbQ!hICJ OJQJaJmHnHuhLCJ OJQJaJht@CJ OJQJaJ!hUrCJ OJQJaJmHnHuht@hCJ OJQJaJ%jht@hCJ OJQJUaJhijhiUhqhr6>*CJOJQJ(hrhr5B* CJOJQJaJphp%hrhrB* CJOJQJaJphphrhr>*CJOJQJ$ 8P$a$ !$hqhr6>*CJOJQJhih8 00&P:p/ =!"#$% ADd P2. b  s >A?Picture 1">A\ s}AD,@=A\ s}|`6@x흽uǵߏs/ )nzR$]K? ^H& .W8o9J6lrެ"*9!Hx*>κ^wy5o{fWp4{Ϟ=^>f9w=#/=NN^kw_~6o__[/o{^/ٱ?'篿ןwor~]7'od 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d 2@ d dիG^!cd f_~{1 1j82@,~駏}ǟ|;ɏ?~|WGi?{)YλulO$ y:!)Ɍ<ɻow]MNN=bx\Ǹ?Oy)r"nO=|^olړ3?>wE~LxY AR݉qʓ76rsKv捏/+qݻow]On<+}_ߡ HR֛{ޘ%Y;|4?wrϺoXJk@G?pɚYjxW{zIU2S'wUۗ[cWX%rܫl_2YS'i}O8L/+f';񽐗[]>*|slN8Z5viY, Xk{'^Rgmƕ}{!/1o?$. 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