Organize requests, functional restrictions, communications, proposed adjustments, responses, and actual work status as distinct records. The worksheet is intended to prevent medical information, employer decisions, scheduling, and pay records from being treated as interchangeable.
Start with the source#
Record the task or working condition at issue, the adjustment requested, who received the request, and what the available documents say. Use the minimum health information necessary for your private review. A publication copy should not contain a person’s diagnosis, treatment history, or medical identifiers.
Working table#
Print this page or reproduce the blank table in a private document. Use “unknown” where the record does not answer a question. The dashes are intentional blank fields, not findings.
| Request/event ID | Work task or condition | Adjustment or functional information | Recipient and source | Documented response | Actual work/pay status and gap |
|---|---|---|---|---|---|
| — | — | — | — | — | — |
| — | — | — | — | — | — |
| — | — | — | — | — | — |
| — | — | — | — | — | — |
How to use the record#
Separate medical clearance from administrative clearance, placement, scheduling, and work actually performed. Track requests for clarification and the response without assuming that either side’s preferred form determines the entire issue. Preserve proposals that were accepted, rejected, withdrawn, or never answered, and identify the evidence for each classification.
Limits and contrary evidence#
The form does not determine disability status, entitlement to accommodation, fitness for duty, safety, undue hardship, or the legal sufficiency of medical documentation. Do not infer an unlawful motive merely from a form request or infer successful reinstatement merely from a clearance letter.
Review questions#
- What function or work condition was addressed?
- What was communicated, to whom, and on what date?
- What evidence distinguishes clearance from an actual opportunity to work?
Related worksheets#
Chronology · Decisionmakers · Adverse Actions and Comparator Evidence
Private use of completed worksheets. This page is a blank organizing aid, not a place to submit records. Keep completed versions and identifying attachments private. Use only information you are authorized to possess and share. Do not post patient, personnel, witness, or privileged material.
This worksheet does not provide legal advice, calculate a deadline, determine a claim, assess clinical care, or replace professional review. It is not an emergency reporting channel.
Important legal-information notice#
KPSGILL.com is not a law firm. No one at KPSGILL.com is a lawyer, and no person associated with the website provides legal advice through these Roadmaps.
The CFMG–Wellpath Claims & Accountability Roadmaps are provided for general educational, research, public-interest, and informational purposes. They explain legal concepts, statutes, cases, procedural issues, evidence considerations, and publicly available records in general terms.
Nothing on KPSGILL.com creates an attorney-client relationship. Reading the website, using a worksheet, following a Roadmap, sending information to the website, or communicating with anyone associated with KPSGILL.com does not make that person your lawyer and does not create attorney-client privilege or confidentiality.
The Roadmaps do not determine whether any particular person has a valid legal claim, who should be sued, what claims should be brought, what defenses apply, what a case is worth, or when an individual filing deadline expires.
Laws, regulations, court decisions, procedural rules, and filing deadlines can change and can depend upon facts, jurisdiction, custody status, employment status, the identity of the parties, and other circumstances. A general limitation period or procedural rule described on this website should never be treated as a calculation of an individual's actual deadline.
Anyone considering a legal claim, responding to a lawsuit, facing a filing deadline, deciding whether to preserve or disclose records, or making another decision with legal consequences should consult a qualified licensed attorney in the appropriate jurisdiction.
Primary sources should be reviewed independently. Where a Roadmap discusses CFMG, Wellpath, counties, clinicians, employers, or other entities, the discussion should not be understood as establishing liability merely because an entity or legal theory is discussed.