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Fit-unfit for work

An eform that you states fitness or inability to work. You can also add a note about reduced duties, graded return etc

HTML icon fit-unfit_for_work.html — HTML, 3 kB (3295 bytes)

File contents


 

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<html>
<head>
  <meta http-equiv="CONTENT-TYPE"
 content="text/html; charset=windows-1252">
  <title>fit-unfit_for_work</title>

   <style>
	<!--

		@page { size: 8.5in 11in; margin-left: 0.79in; margin-right: 0.79in; margin-top: 0.5in; 		margin-bottom: 0.5in }
		
		body { font-family: "Times New Roman", serif; font-size: 12pt; background-color:#fdfec7  }

		P { margin-bottom: 0.08in; direction: ltr; color: #000000; widows: 2; orphans: 2 }
		
		p.small { margin-right: 0.5in; margin-left: 0.5in; font-family: "Times New Roman", serif; 
		font-size: 10pt  }
		
		p.bold { margin-bottom: 0.08in; direction: ltr; color: #000000; widows: 2; orphans: 2; font-weight:bold }


		H1 { font-family: "Times New Roman", serif; font-size:24pt; text-align: center }

		table.head  {width:100%; border-top-style: solid ; border-style: none;  font-family: "Times New Roman", serif; font-size: 10pt  }

		.button { font-family: "Times New Roman", serif; font-size: 12pt }
		
		textarea { overflow: hidden;  border-width: 0;  font-family: "Times New Roman", serif; font-size: 12pt }
		
		input.noborder { border : 0px; font-family: "Times New Roman", serif; font-size: 12pt  }
		
		
	-->
	</style>

<style media="print">
.hide {
display:none }
</style>
</head>
<body>

<p  align="center" style="border-style: double none none; border-color: rgb(0, 0, 0) -moz-use-text-color -moz-use-text-color; border-width: 1.1pt medium medium; padding: 0.02in 0in 0in; margin-bottom: 0in;"></p>

<H1>Name of Medical Clinic</H1>

<p  align="center" style="border-style: double none none; border-color: rgb(0, 0, 0) -moz-use-text-color -moz-use-text-color; border-width: 1.1pt medium medium; padding: 0.02in 0in 0in; margin-bottom: 0in;"></p>
<br>

<form name="form1" method="post" action="">


<table class="head">
  <tr>
    <td width="50%" valign="top">

<input type="checkbox" name="C1" value="ON">Dr's Name Here<br>


    <td width="50%" valign="top" align="right">Dr's address here<br>

City Here<br>
Province and Postcode here<br>

Phone: Number here<br>

FAX: Number here
</td>
  </tr>
</table>

<p>
<input type="text" name="date" size="20" oscarDB=Today class=noborder>
</p>







<P>To whom it may concern:</P>


<br>

<P>
<input type="text" name="name" type="text" size="20" oscarDB=patient_name class=noborder>
</P>
<p>
<input type="checkbox" name="C1" value="ON">is fit for work
</p>
<p>
<input type="checkbox" name="C1" value="ON">is unfit for work
</p>



<p>
The return to work should take account of:</p>

<p>
<input type="checkbox" name="C5" value="ON">Graduated return
<br>
<input type="checkbox" name="C6" value="ON">Modified duties
<br>
<input type="checkbox" name="C7" value="ON">Light duties
<br>
<input type="checkbox" name="C8" value="ON">Restrictions
</p>

<p>

<textarea name=reason cols="75" rows="20" wrap=hard ></textarea>

</p>


<p class="bold"> 
Signed:</p>

<br>
<br>

<p class="hide">
 <input type="submit"
 value="Submit" name="B1" class="button">
 <input type="button" value="Print" onclick="javascript:window.print()"  class="button"> <br>
  <input type="button" value="Close Window"
 onclick="javascript:self.close();"
 onkeypress="javascript:self.close();" class="button"></p>
 </form>
</body>
</html>
            

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