ࡱ> Y[X` bjbjss 5&Mbbbbbbbv 8 4vuQFFFFFFFF~:F1P$7ShUbP9b*FF**PbbFF/Q*XbFbF~*~bbF: 0 XEQ0uQWdWWb4F"hFFFPP>XFFFuQ****vvvD vvv vvvbbbbbb  STATE OF MARYLAND FAMILY AND MEDICAL LEAVE RETURN TO WORK MEDICAL CERTIFICATION FORM (Type or Print) PART I EMPLOYEE INFORMATION Name:  Title: Department:  Date Leave Commenced:  Date of Return to Work:  Employee's signature: ______________________________ Date: ______________________  PART II TO BE COMPLETED BY EMPLOYEE'S HEALTH CARE PROVIDER I certify that on _______________    " .     * f l n p * , t z | ~ 2 468 Uh6CJOJQJ]^Jh>*CJOJQJ^Jh>*OJQJ^JaJhOJQJ^JaJhCJOJQJ"h56CJOJQJ\]^Jh5CJOJQJ\^JhCJOJQJ^J2&\      :$If$IfBkd$$Ifx''  4 xaxp   :$If d$If  f h j l v x z \Ekd7$$Ifx0'4 xax d$IfEkd$$Ifx0'4 xax:$If$If z ~ * , . 0 g^ $$Ifa$BkdO$$Ifx''  4 xaxp   :$If d$If2kd$$Ifx''4 xax:$If$If (date), I examined ______________________ (name of employee), and on the basis of my examination, this employee is ready to return to work and is able to perform the functions of his/her position. 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