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Get Calhr 754 2016-2024

Age 1 of 3 (rev 4/2016) Employee Last Name Employee First Name Employee Middle Name 6. Is the employee unable to perform any of the job functions due to his/her medical condition? Yes No (See attached Essential Job Functions and/or attached Job Description): If yes, identify the job functions the employee is unable to perform, work restrictions and probable duration: 7. Can the patient perform modified duty? Yes No If yes, state the type of modified duty the employee is able to perform .

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