Heavy Equipment Physician

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Fitness for Duty Release Form

Employee Name: Employee ID:

Job Title:

EMPLOYEE: Complete this section prior to submitting to Physician: Employee Number #: Date of Birth: / / Employee Phone #: The employee listed above has been under your care for a medical condition. Attached are the Essential Physical Requirements for this employee’s position. Please review to determine if the employee is able to meet these job requirements. If you have questions, contact Ulta Beauty at 844-***-****. Date of injury/surgery/onset of illness: Diagnosis or description of injury/surgery/illness: Please check the status of the employee’s release to duty: Full duty (without restrictions) effective date: DO NOT COMPLETE PAGE 2 IF EMPLOYEE IS FULL DUTY

Modified duty (with restrictions) effective date: Next evaluation date: You must complete page 2 (Injury/Illness RTW Status form) Not released for any type of duty. Next evaluation date: Date of expected full duty release: Physician’s Signature: Date: Physician’s Printed Name: Address: Phone#: City, State, Zip Code: ULBE-406-242001933587

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INJURY/ILLNESS RETURN TO WORK for:

Use this form to identify the work restrictions or major life activities affected by the physical or mental impairment of this individual, based on the doctor’s best understanding of the employee’s essential job functions/physical requirements (attached).

Maximum Hours per Day

0 2 4 6 8 Other

Posture Restrictions: Miscellaneous Restrictions:

Standing Max hours per day of work: Sitting Sit/Stretch break of per Kneeling/Squatting/ Desk work only Crawling Must wear splint/cast at work

Bending/Stooping Must use crutches at all times Pushing/Pulling No driving/operating heavy equipment Twisting Can only drive automatic transmission Other: No work/ hours/day work:

In extreme hot/cold environments

At heights or on scaffolding

Motion Restrictions: Must keep Walking elevated clean & dry Climbing stairs/ladders No skin contact with: Grasping/Squeezing

Wrist flexion/extension

Reaching Medication Restrictions: Overhead Reaching Must take prescription medication(s) Keyboarding/typing Advised to take over the counter meds Other: Medication may make drowsy

(Possible safety/driving issues)

Lift/Carry Restrictions: Major Life Activities Affected:

May not lift/carry objects more than lbs. Self-Care Bending for more than hours per day Working Speaking

May not perform any lifting/carrying Seeing Breathing

Other Hearing Learning

Eating Reading

Sleeping Concentrating

Restrictions specific to (if applicable): Walking Thinking

Neck Shoulder Standing Communicating

Upper Back Lower Back Lifting Performing manual

Arm Elbow Other tasks

Wrist Hand

Hip Leg

Knee Ankle *WORK RESTRICTIONS:

Foot Can work call duty:

Other Can work overtime: Side Affected (*Call Duty/Overtime require employees to work over 40 hours a week.)

Left Right Both

ULBE-406-242001933587

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Other Restrictions (if any):

ULBE-406-242001933587

Contact this candidate