Occupational Medicine
A Basic Guide

04: Fitness for Duty

Introduction: What is fitness for duty?
Tanisha Taylor, MD, MPH, CPE, FACOEM

Being fit for duty means that an employee’s physical, emotional, and mental condition allow him or her to perform essential job duties in a proper, safe, and competent manner. An unfit employee is one who cannot perform those duties according to these standards, regardless of the reason. Employees are expected to report to work fit for duty and remain fit while on duty. It is the responsibility of supervisors to monitor employee performance and behavior, to require fitness for duty, and to have policies in place to ensure worker fitness.


Fitness for Duty (FFD) evaluation is a medical evaluation performed by a licensed medical practitioner at the request of an employer. These evaluations are conducted to determine work-duty assignments among a variety of employment settings. Certain employees, such as law-enforcement officers and firefighters, undergo evaluations at regular intervals (such as annually) due to the rigorous physical requirements and medical standards required by their work. Medical guidelines are produced by regulatory agencies to help providers make decisions regarding these groups. However, even an employee in a sedentary job may require an FFD due to cognitive or behavioral issues or physical conditions such as carpal tunnel syndrome.


FFD exams are also required by statutory mandate in certain industries. For example, the Federal Motor Carrier Safety Administration, Federal Aviation Administration, and Occupational Safety and Health Administration (OSHA) require certain workers (truck drivers, pilots, and asbestos workers, for example) to undergo medical exams on a periodic basis.


Various types of FFD tests are conducted to determine whether an individual is fit for work at the time of hire or upon return to work following injury, illness, or prolonged absence, or when there is concern about whether a worker can safely perform the job (“for cause”). These tests may also be performed periodically for high-risk and safety-sensitive professions (for example, firefighters, law-enforcement officers, and emergency medical technicians).


A variety of laws and regulations govern the timing and scope of FFD requests, including those outlined by the Americans with Disabilities Act (ADA), Equal Employment Opportunity Commission (EEOC), Genetic Information Nondiscrimination Act (GINA), and Health Insurance Portability and Accountability Act (HIPAA).


An FFD examination administered by a healthcare provider may be given only after a job offer has been made. It is strictly prohibited to ask a prospective employee in the pre-offer stage to submit to a FFD examination. However, an employer can make pre-employment inquiries into the prospective employee’s ability to perform job-related functions or perform an agility test without medical examination or monitoring. An employer is allowed to make a job offer conditioned upon the successful completion of a medical exam if two conditions are met:


  • The examination is applied uniformly to all entering employees in the same job category
  • The employer legally must base its decision only on information directly related to job fitness. (For this reason, employers are advised not to acquire any additional medical information from the FFD evaluator, and if they do, not to place it in an employee’s file )


Further, an employer can request an FFD exam when:


  • An individual has applied for or occupies a position with physical requirements or medical standards
  • An employee has applied for or is receiving continuation of pay or compensation as a result of on-the-job injury or disease
  • An employee is given a transfer or promotion, and the position to which the employee has reassignment rights has medical standards or specific physical requirements that are different from those of the employee’s previous position.


Reasons for an FFD Referral


The reasons that an employee might be, or become, unfit are many. They include, for example, physical problems, mental illness, drugs or alcohol use, prescription medication use, stress or other emotional problems, work-related injuries, and non-work-related accidents or other issues.

Generally, when a manager or supervisor observes a change in an employee’s behavior or capacities that presents a direct threat of harm to self or others, the manager, in consultation with human resources staff, can investigate to see whether there is a reasonable explanation for this change and whether a “for cause” FFD evaluation is warranted.


An employer may require an employee to undergo an FFD examination for a number of reasons. In some cases, an employee has exhibited a sustained pattern of poor performance of duties. In other cases, the employee may have exhibited a gradual or sudden deterioration of performance, which may or may not have been documented in the personnel file. An FFD exam may be triggered when an employee poses an imminent and serious safety threat to him- or herself or others or is generally having difficulty performing work duties in a manner that is safe for the employee, clients, public, or coworkers. An FFD exam also might be triggered by unclear written correspondence, inaccuracies in work, or the need for unusually close supervision. Documented factors such as low mood and poor attitude in response to criticism that interfere with work may also indicate a need for such an exam.


The question of whether to perform the evaluation is always based on whether the employee is capable of performing the necessary job duties and doing so safely. In addition to providing the FFD evaluator the reason for the referral, the employer also must provide the job description and accurate portrayal of job duties.


Potential Outcomes


Fitness for duty evaluations can result in a variety of outcomes, ranging from a safe return to work, either with or without accommodations, immediate termination, referral to a specialist for further evaluation, or referral to an employee assistance program. Sometimes the FFD evaluation is unrevealing or even turns out to have been inappropriately referred.


The Evaluation Process


The mechanisms that FFD evaluators use to evaluate fitness for duty include a verbal interview, observation, and physical examination. In some cases, job-simulated functional tests are also used to determine fitness for duty. When performing an FFD evaluation, in addition to considering legal regulations, addressed later in this chapter, the evaluator must consider workplace policies (such as whether an employee works in an established Drug-Free Workplace), individual job duties, and safety or competency criteria for the individual’s job.



An FFD interview should be conducted in a private location by a qualified evaluator. It is preferable to have another appropriate member of the care team present.


The evaluator must take a full medical history, including an assessment of activities of daily living and instrumental activities of daily living; a social history; and occupational history. With the advent of GINA, family medical history information generally should not be obtained during a medical examination. However, there are exceptions when information derived from a family medical history is [See below, Genetic Information Nondiscrimination Act (GINA) of 2008.]



An FFD evaluator may make observations regarding the examinee’s gait and posture walking and standing, speech, eyes, face, appearance, breath odor, eating and chewing, demeanor, actions, and cognitive abilities.


Physical Exam

In general, FFD test protocols include a medical/physical examination. A basic physical examination may include vital signs, coordination testing, and a mental status examination. Advanced evaluations may include psychometric testing or neurocognitive testing.


Functional Testing

Job-simulated functional capacity evaluations may include stair or ladder climbing and postural, lift, carry, push, and pull tests that represent physical work demands specific to the individual’s job.


Very often, evaluations are not completed in one sitting, and additional evaluation and referrals may be necessary. The evaluator may call for special medical tests (such as radiographs, MRIs, pulmonary function studies, and so on) that are deemed appropriate for the job in question. In some cases, consultation with additional specialists and/or the employee’s personal physician may be appropriate. Sometimes, a safety assessment by an industrial hygiene officer or safety officer within the employer’s company is requested.


Often, health conditions, such as cardiac issues, arise during the FFD evaluation. The evaluator may at times send a patient to his or his health care provider to contribute to the evaluation. In these cases, the FFD evaluator serves as a mediator between the patient’s doctor and the employer’s human resources department, ensuring confidentiality of all medical information. Adverse actions (such as the withdrawal of a job offer) can be taken only against an examinee based on tests that are job-related


Neuropsychological Testing

Neuropsychological testing may be required when an employee has a pattern of compromised performance that is not attributable to issues such as lack of training or poor supervision. It can also be used to set a baseline of cognitive performance when an employee is being monitored for progression of disease or disability or to help differentiate between compromised cognition and stress-related cognitive complaints.


Neuropsychological tests compare individuals’ cognitive abilities to a normative standard, and their results can indicate impaired behavior that might compromise safety on the job. Employers must be careful not to use this type of testing to address behavioral or interpersonal issues that are best addressed by administrative or human resources interventions or through training.


A decrease in neuropsychological capacities may compromise safety-sensitive tasks. Therefore, neuropsychological tests must be performed when tasks require vigilance and working memory, when the examinee is driving or operating vehicles, and when fine-motor coordination and steadiness are required to perform sensitive operations (for example operating machinery, discharging a weapon, or performing surgery).


A growing issue in FFD examinations is workplace violence. Committing a verbal or physical assault constitutes a clear medical and/or psychiatric emergency, and in that case a worker may be referred for a psychiatric FFD evaluation. The evaluator’s first interest is always that of the patient and how the patient’s safety and immediate needs, as well as safety of coworkers, will be best met when considering whether to send him or her back to work. Primum non nocere; that is, first do no harm. In an event where behavior does not require immediate intervention, a medical evaluation may be appropriate. The evaluator makes such determinations.


In all FFD evaluations, documentation is extremely important and should include specific observations as much as possible. The evaluator should remain objective and nonjudgmental, assessing in an unbiased way an employee’s physical characteristics, intellectual ability to perform, and interpersonal behavior and judgment.