Fire Fighter ClearPath Form

For physician guidelines on evaluating a fire fighter, please click here.

ClearPath Return to Work Form-Fire Fighter

Employee Information Section

Department Communication Requirements

Attending Provider Section

I certify that the employee named above has been under my care. *
Please check any suddenly incapacitating event below if it has been associated with this specific injury/illness/condition. *
Any short-term or permanent prescriptions for anticoagulants? (i.e. warfarin, eliquis, pradaxa, etc) *
Any significant residual orthopedic deficits? *
Any significant residual neurologic deficits? *
Any ongoing prescription for daily sedatives/narcotics required? *

Attending Provider Duty Recommendations

Please Select One of the Following as Your Recommendation and then Answer the Associated Questions as applicable. *
Please Check if the Fire Fighter is Unable to Perform any of the Following: *
Please Check if the Fire Fighter is Unable to Perform or will have Limitations with any of the Following: *

Public Safety Medical Opinion

Public Safety Medical Work Status Recommendation *
Status of Driving Department Vehicles *