FormsStaffForms → Return to Work Evaluation for Temporary Employees

Return to Work Evaluation for Temporary Employees

About this Form

Form number: 440-40T

Audience:  MCPS Staff

Last revised: July 2018

PART I—Employee: Employees complete Part I of this form and access their job description via If the job description is unavailable, employees should contact their immediate supervisor.

PART II and Part III—Physician or Health Care Practitioner: The physician or health care provider should review the employee’s current job description, complete Part II and III of this form, and return the form to the employee. Thank you for assisting in our efforts to return our employee to work in a safe and timely manner.

PART IV—Employer: MCPS will determine the employee’s ability to return to work based upon the job description and listed restrictions.

Adobe PDF Return to Work Evaluation for Temporary Employees146 KEnglish

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat