FITNESS-FOR-DUTY LETTER

[Clinic name]
[Address]
[Phone]

Date: [Date of letter]

To: [Employer, or its occupational health contact]
Re: [Patient's full name]
Date of birth: [Date]
Job title: [Job title]
Your request: [Date of the employer's request, and any reference number]

[Patient name] asked me to answer this request and agreed to what this letter shares.

QUESTION ASKED
[The employer's question, in its own words]

BASIS OF MY OPINION
My role: [Treating physician, nurse practitioner, or other role, and since when]
Assessed: [Date, and in person or by video]
What I reviewed: [History, examination, tests, and records that bear on the duties]
Job information: [The job description or duty list the employer sent, or the patient's own description]

EACH ESSENTIAL DUTY
[Duty 1]: [Fit, fit with limits, or not fit, and until when]
[Duty 2]: [Fit, fit with limits, or not fit, and until when]
[Duty 3]: [Fit, fit with limits, or not fit, and until when]
Limits: [Each limit in concrete terms: how much, how often, and its end date]

OVERALL
Opinion: [Fit for the listed duties, fit with the limits above, or not fit for them at present]
From: [Date]
Until: [End date of any limits, or the review date]
Review: [Date I will reassess]

OUTSIDE MY ASSESSMENT
[Duties or standards I can't assess, e.g. a licensing medical standard, a functional capacity test, or a specialist evaluation, and who can assess them; or none]

MEDICAL INFORMATION
[None beyond this letter, or what the patient agreed to share and why the duties need it]

[Your name, credentials]
[License or registration number]
[Signature]
[Phone or email for questions about this opinion]