Example Work Restrictions Response Letter & Employee Acknowledgement Form

When an employee takes FMLA leave due to a personal injury or illness, a doctor or other treating medical practitioner must clear them to return to work. This letter is to provide to the employee once you have received the Fitness for Duty form from the treating medical practitioner to define the terms of their return, such as any restriction of duties. The employee should complete the acknowledgement on page two and return it for their file.

[Denotes a field that needs to be modified]


[Employee Name]
[Street Address]
[City, State ZIP]


Dear [Employee Name]:

We have modified your job duties to ensure compliance with your doctor’s orders. Your health and safety is of upmost importance to us. Therefore, we ask that you exercise caution when you return to work and that under no circumstances do you perform a job duty that requires you to perform a restricted motion as per your physician’s letter.

On the letter provided to us on [Date] from your treating physician, your treating physician, has listed the following work restrictions:

[List restrictions]

It is important that you do not attempt to perform any of these activities upon your return to work. If a job duty needs to be performed that involves one of these restricted activities, you are required to delegate the job duty to another employee. Until you are further along in your recovery and these restrictions are lifted, under no circumstances are you to disregard these restrictions while performing work for [Company Name].

Please be assured that your disability records will be maintained in accordance with applicable confidentiality requirements as delineated in the ADA.

Again, we are glad that you are back!


[Name and Position Title]
[Contact Information]

(Page 1)


I, ___________________________ (Employee Name) understand that my treating physician has released me to return to work as of [Date] with the following restrictions:

[List restrictions]

I understand that under no circumstances am I permitted to perform job duties that requires me to violate the above listed restrictions. Should such job duties need to be performed, I will ask or delegate another team member to perform them. I understand that my inability to perform these motions at this time will not be taken into account when my performance is reviewed and I will not be retaliated against based on my current medical status or work restrictions. Should I have any concerns in this regard, I will immediately bring them to the attention of the Human Resources Department.

I understand the restrictions listed here and agree to follow them at all times during the course of my work at [Company Name] (until your doctor revises the restrictions).

Employee Name: ______________________________________________________________________________

Name (print): _________________________________________________________ Date: _________________

(Page 2)

Please note that this document is intended for informational purposes only, and does not constitute legal information or advice. If you need additional assistance or would like to learn more about Solid Business Solutions and our Houston PEO solution for your business, please contact us today at (888) 762-2075.

Learn more about Solid: Texas PEO, Austin PEO, Dallas PEO, Houston PEO.

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