Work capacity certificate template
Addressed to whom it may concern, on the day of the consultation.
- Absence from work
- First and last day certified.
- Fitness for duties
- Unfit, modified duties, or fit.
- Restrictions
- Lifting, hours, driving, other.
- Expected return to work
- Date, subject to review.
Worked examples
Work certificate · unfit for a period Shaw, Jason · 38M · Synthetic patient
Absence from work 14 July to 21 July 2026 inclusive. Fitness for duties Unfit for all duties for that period. Restrictions No driving while taking the prescribed analgesia. Expected return to work 22 July 2026 on modified duties, subject to review at the appointment on 21 July.
Work certificate · modified duties Ross, Emily · 31F · Synthetic patient
Absence from work Not applicable. The patient remains at work. Fitness for duties Fit for modified duties from 5 August to 2 September 2026. Restrictions No lifting above 5 kg. No work at heights or on ladders. Maximum six hours per shift, four shifts per week. Seated tasks where available. Expected return to work Full duties from 3 September 2026, subject to review on 1 September.
Work certificate · return to full duties Ross, Emily · 31F · Synthetic patient
Absence from work Not applicable. The patient has been on modified duties since 5 August 2026. Fitness for duties Fit for full duties from 3 September 2026. Restrictions Nil. Expected return to work Full duties resumed. No further certificate is expected unless symptoms recur.
