Prescription and Over-the-Counter Medications Tool Kit ... - Home

Subject:
Substance Abuse- Drug Free Workplace
No.
40-22
Page:
7 of 7
MUNICIPALITY OF ANCHORAGE
Physician’s Statement
Employee’s Name: ___________________________________________________
Date(s) of Treatment: ___________________________________________________
Will any medication(s) prescribed impair the employee’s job performance, including the ability to drive and
operate equipment? ____________________________________________
Employee is released to return to work with no restrictions on: _____________________
(date)
Or, with the following restrictions (include driving restriction if appropriate):
______________________ __________________________
Physician’s Signature Date