How to Complete a Fitness for Duty Mental Health Evaluation Form

A fitness-for-duty evaluation form documents whether an employee can safely perform the core tasks of their job, based on a clinical assessment rather than a supervisor’s guess. To complete one correctly, the employer fills in the employee’s information, a factual reason for the referral, and a specific list of essential job functions; attaches the GINA safe harbor notice; and sends the form to a qualified medical provider who examines the employee and returns a determination of fit, unfit, or fit with restrictions. Getting each section right matters. An incomplete referral can delay a return to work, and a sloppy one can expose the employer to disability discrimination claims.

Confirm the Referral Meets the ADA Standard

Before anyone picks up the form, confirm the reason for sending the employee is one the law allows. Under the Americans with Disabilities Act, an employer can require a medical examination of a current employee only when it is job-related and consistent with business necessity.¹ That standard is met when the employer has objective evidence suggesting either that the employee may be unable to perform essential job functions because of a medical condition, or that the employee may pose a direct threat to their own safety or others’.²

A vague feeling that something is off does not clear that bar. Documented observations or concrete performance data do. Common triggers include an employee returning from a serious medical leave, repeated safety incidents or erratic conduct, a workplace accident or confrontation that raises questions about capacity, and periodic examinations required in public safety fields like law enforcement, firefighting, and aviation.² An employee who discloses a medical condition does not automatically become a candidate. There has to be a reason tied to actual job performance or safety.

Identify the Essential Functions First

The foundation of any usable form is a clear picture of what the job actually requires. The ADA defines a qualified individual as someone who can perform the essential functions of the position, with or without reasonable accommodation.³ Essential functions are the fundamental duties of the job, not every task listed in a job description.⁴

Several factors help sort essential from marginal: the employer’s own judgment, written job descriptions prepared before recruiting for the role, the amount of time spent performing the function, the consequences if nobody performs it, and the experience of past and current employees in similar positions.⁴ A warehouse job whose primary task is loading pallets has lifting as an essential function. A desk job where someone occasionally carries a box of paper to the copier room probably does not.

Document the physical demands (lifting thresholds, standing duration, exposure to specific environments) and the cognitive requirements (sustained concentration, decision-making under pressure, operating heavy equipment). This list goes directly onto the form so the evaluating provider knows exactly what capacities to assess. Vague language like “must be physically fit” gives the provider nothing to work with and can make the entire evaluation legally questionable.

Fill In the Employer Section

Most forms start with a section the employer completes before the employee sees a provider. Organizations typically obtain these forms through their occupational health clinic, HR information system, or a contracted risk management vendor. There is no single universal federal template, though the required content stays consistent.

The employer section covers four things:

Employee information: full name, job title, department, employee ID, and supervisor name.
Reason for referral: a factual, specific explanation of what prompted the evaluation. “Employee was involved in two forklift near-miss incidents on March 3 and March 10” works. “Employee seems unwell” does not. The language should describe observable behavior or documented events, not speculate about diagnoses.
Essential functions: the list of job duties the provider needs to evaluate against, with measurable details like weight limits, shift duration, equipment operated, and environments encountered.
Specific questions for the provider: whether the employee can perform the listed functions, whether any restrictions apply, and whether the employee poses a direct threat to safety.

This is where most FFD processes go sideways. A referral that names or implies a suspected diagnosis crosses into disability-related territory the employer should avoid. Stick to what you observed, not what you think is causing it. HR departments that have legal counsel review the referral language before sending it out save themselves considerable trouble later.

Attach the GINA Safe Harbor Notice

Any form requesting medical information should include the safe harbor notice required by the Genetic Information Nondiscrimination Act. GINA prohibits employers from requesting or requiring genetic information, which includes family medical history, from employees. Because a medical provider responding to the form might inadvertently include family history, the safe harbor language tells them not to. If genetic information does slip through, the employer can argue the disclosure was inadvertent.⁵

The recommended language reads: “The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.”⁵ Print it verbatim on the form or attach it as a cover sheet. Omitting it removes the employer’s best defense if genetic information ends up in the file.

What the Provider Does With the Form

A qualified medical professional, typically an occupational medicine physician (a psychologist or psychiatrist for mental health concerns), reviews the essential functions list and reason for referral, then performs whatever examination and testing are necessary to determine whether the employee can handle those specific demands. The scope of the evaluation must stay limited to the condition or concern that triggered the referral.⁶ The employer pays for the evaluation. If the employee later wants a second opinion from a different provider, that cost falls on the employee.

When safety is the concern, the provider conducts a direct threat analysis. Under the ADA, a direct threat is a significant risk of substantial harm that cannot be eliminated or reduced through reasonable accommodation.⁴ The determination must be individualized and grounded in current medical knowledge and objective evidence, not speculation.⁷ A form where the provider simply checks “direct threat” without documenting the analysis may not hold up to scrutiny.

Reading the Provider’s Determination

The provider concludes with one of three findings: fit for duty without restrictions, unfit for duty, or fit with specific restrictions. Restrictions should describe functional limitations (“cannot lift more than 20 pounds,” “must take a 10-minute break every two hours”) rather than naming the underlying medical condition. The provider reports what the employee can and cannot do, not why.

If the employee is cleared without restrictions, return-to-work is straightforward. If unfit, the employer documents that finding and considers continued leave, reassignment, or separation, depending on the circumstances and any FMLA or other leave protections. A fit-with-restrictions finding triggers the ADA’s interactive process: the employer and employee work together to identify whether a reasonable accommodation, such as modified duties, adjusted schedules, or assistive equipment, can bridge the gap. Unnecessary delays in that process can themselves violate the ADA.⁸

Transmitting and Storing the Completed Form

The completed form goes back to HR or whoever manages confidential medical files, not to the employee’s direct supervisor. Use a secure channel: an encrypted upload to the HR system, a secure fax line, or a sealed envelope marked confidential if delivered physically.¹

The ADA governs how the form is stored and who sees it. Medical information from the evaluation must be kept on separate forms, stored in separate medical files apart from the regular personnel folder, and treated as confidential.¹ Only a narrow group can access the information:

Supervisors and managers may be told about necessary work restrictions and accommodations, but not the diagnosis behind them.
First aid and safety personnel may be informed if the condition could require emergency treatment.
Government officials investigating ADA compliance may request relevant information.¹

A supervisor who tells the rest of the team why an employee was out or what the doctor found has just created a confidentiality violation. Retain the form and any supporting clinical documentation for at least the duration of the employee’s tenure, plus enough time to cover any potential discrimination claim. Federal regulations generally require retention of personnel and medical records for at least one year after the record is created or the personnel action is taken, though many employers keep medical records longer as a practical matter.¹

If the Employee Refuses the Evaluation

An employee who refuses a lawfully required evaluation puts themselves in a difficult position. The EEOC’s guidance is direct: when an employer reasonably believes an employee has performance problems due to a medical condition and the employee refuses to cooperate, the employer may discipline the employee for the performance issues the same way it would handle any other employee with similar problems.² In practice, employers often place a refusing employee on administrative leave and, if the refusal continues, proceed to termination. An employee who believes the request is discriminatory can challenge it, including by filing a charge with the EEOC. The employer’s documentation of the objective evidence that prompted the referral is what protects it in that scenario, which is another reason the referral section of the form matters so much.

A Note on FMLA Return-to-Work Certifications

If the evaluation follows FMLA leave specifically, a separate set of rules applies. An employer with a uniformly applied policy may require fitness-for-duty certification before restoring the employee to their position. If the employer wants that certification to address essential functions, it must provide the employee with a written list of those functions no later than the FMLA designation notice; miss that window, and you cannot demand the certification cover essential functions at all. No second or third medical opinions are permitted on an FMLA fitness-for-duty certification, unlike the process for initial FMLA medical certifications.⁶

1
eCFR. 29 CFR 1630.14 – Medical Examinations and Inquiries Specifically Permitted
2
U.S. Equal Employment Opportunity Commission. Questions and Answers: Enforcement Guidance on Disability-Related Inquiries and Medical Examinations Under the ADA
3
Office of the Law Revision Counsel. 42 USC 12111 – Definitions
4
eCFR. 29 CFR 1630.2 – Definitions
5
eCFR. 29 CFR 1635.8 – Acquisition of Genetic Information
6
eCFR. 29 CFR 825.312 – Fitness-for-Duty Certification
7
U.S. Equal Employment Opportunity Commission. Enforcement Guidance on Disability-Related Inquiries and Medical Examinations of Employees Under the ADA
8
U.S. Equal Employment Opportunity Commission. Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the ADA