DKC-E2

___________________District

Certificate of

Fitness for Duty

_______________________ (employee’s name) is a patient of mine.  It is my understanding that _______________________’s (employee’s name) employment with the __________ School District requires him/her to be able to perform the following activities with accompanying weekly time requirements:

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            On ______________,(date) I personally evaluated ____________________ (employee’s name).  I certify that based upon my education and clinical expertise ______________________ (employee’s name) is fit to return to his/her employment with the ____________________ District. 

                                                                                                                                                                                                            ____________________________________

Signature

                                                            ____________________________________

Title