Fitness-for-Duty Scheduling

Please use the following form to request an appointment for a Fitness-for-Duty evaluation.  

Based upon your request(s), we will call to confirm your information and e-mail you a schedule confirmation within 1 business day.  Thank you.

Don’t want to send your personnel to our office?  Check out our ClearPath™ program by clicking here.

Name of Department or Office *

Name of Person Making Request *

Title of Person Making Request *

E-mail of Person Making Request *

FAX Number of Person Making Request *

Direct Phone Number of Person Making Request *

Chief of Department *

Please Provide the Department's Mailing Address *

Do you want to receive an emailed copy of this submission?

Yes

No

Who Should Receive the Results? (check all that apply) *

"Person Making Request" Above

The Chief Named Above

Someone Else

Chief's Direct Phone Number (if not already provided)

Chief's FAX Number (if not provided above)

Name to Whom Results should be Sent *

Title to Whom Results Should be Sent *

FAX Number of Person to Receive Results *

Invoices Should Be Sent To:

Name to Send Invoice To *

Title *

E-Mail *

Phone *

Do You Require a Purchase Order? *

Yes

No

Attach PO if Possible

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Maximum file size: 2MB

Address *

Is this the same person who will be paying the bill? *

Yes

No

Payables Contact Person *

Payables Contact Phone Number *

Payables Contact E-mail Address *

Reason for Visit

Name of Employee *

Date of Birth of Employee *

Employee Position *

Current Duty Status * On DutyOff DutyLight DutyAdmin LeaveDisabled

Use Drop Down

How Many Calendar Days Has it Been Since this Employee Was On Duty?

Date Employee Began this Status *

Has the Employee Been Released by their Treating Physician? *

Yes

No

I Don't Know

Date Released to Return to Full Duty by their Treating Physician

Please Attach Physician's Release or e-mail to alexis.henry@ascension.org as soon as possible.

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Maximum file size: 2MB

Next Duty Date *

Is this a Disability Evaluation? *

Yes

No

Please Select "Disability" from the Drop-Down Box on the Next Question.

Reason for Being Off Duty * HospitalizationMinor IllnessMinor SurgeryMinor InjuryUncomplicated FractureSprain, Strain, ContusionsPerformance IssuesNeurological Conditions (stroke, TIA, paralysis)Orthopedic (Joint replacement, spinal fusion)Endocrine (Diabetic, insulin issues)Cardiac (MI, cath, surgery, arrhythmia)Failed WPESick Leave-90 day extensionAdmin LeaveDisabilitySick Leave ReviewPolice Action Shooting-PSYCHReturning from Military Leave-PSYCHDrug/Alcohol Concerns-PSYCHEmotional Distress-PSYCHOther Mental Health Issue-PSYCHAdministrative Concerns

Use Drop Down

Please Provide the Specific Issue, Illness or Injury Leading to this Person Being Taken Off Duty. *

i.e. broken left arm, torn left leg ACL, rotator cuff tear in right shoulder, symptoms of depression, etc.

Is this a Follow-Up Evaluation with Public Safety Medical? *

Yes

No

Not Sure

If Known, Please Select the Name of the Original Examiner (can be found at bottom of "Ability to Work" form). *

Dr. Moffatt

Dr. Pate

Anne Mundrick

Kelli Tharpe

Valerie Smith

Kathy Zach

Not sure

What Are Your Concerns About This Employee's Behavior or Performance? *

Please Indicate the Services you are Seeking. *

Medical evaluation only

Psychological evaluation only

Both medical and psychological evaluation

Additional Testing Requested (Check all that apply) (PSM may suggest other testing based upon condition) *

Vision Testing

Hearing Testing

Drug Testing

Treadmill Testing

Pulmonary Function Testing

OtherOther

No additional testing requested

Is this a Workers' Comp Claim? *

Yes

No

Has there been an Independent Medical Evaluation (IME) Performed? *

Yes

No

I Don't Know

Has this Employee Sought Legal or Labor Counsel? *

Yes

No

I Don't Know

Please Briefly Explain: *

When Do You Need This Appointment? *

Psychological Evaluation Questions

PSYCH EVALUATION QUESTIONS: When Was this Employee Hired?

Please Attach Documents that Substantiate the Need for a Psych Fitness for Duty Evaluation (i.e. memo from supervisor, arrest report, etc.)

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Maximum file size: 2MB

Please Attach the Employee's Job Description

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Maximum file size: 2MB

Has the Employee Had Recent and Formal Disciplinary Problems? (i.e. written reprimand, suspension, demotion)

Yes

No

Please Attach Documentation of These Disciplinary Problems if Available.

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Maximum file size: 2MB

Please Provide any Other Comments on These Disciplinary Problems.

Is the Employee a Defendant in a Pending Legal/Criminal Case?

Yes

No

Don't know

Please Describe the Circumstances

If the Employee has been Off Work Recently, are They Now Certified by a Physician or Psychologist to Return to Work?

Yes

No

Don't know

Please Explain and Clarify if the Employee Has Been on FMLA Leave.

Please Provide Any Other Helpful Information That May Have Importance to the Decision to Refer this Employee.

Any Other Comments or Attachments? (Use File Upload Below)

File Upload

Drop a file here or click to upload Choose File

Maximum file size: 2MB

PLEASE CLICK "SUBMIT" BUTTON AT BOTTOM OF PAGE.

STOP: PSM Use Only

EXAM TYPE

FFD Follow-Up Evaluation (PSM USE ONLY)

PSYCH EVAL (PSM USE ONLY)

PSYCH EVAL (PSM USE ONLY)

Level 1 Evaluation (PSM USE ONLY)

Level 2 Evaluation (PSM USE ONLY)

Level 3 Evaluation (PSM USE ONLY)

PSM USE ONLY: Is this a New Client?

Is there an Existing WPE?

What Type of Evaluation is this?

FFD

RTW

Disability

Case Management

Date of Last Physical?

Applicable Department Write-Ups/Documents Obtain applicable docs

Client Medical Records Obtain applicable records

Additional Comments Provide comments

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