Statement Of Fitness For Work Form Template for Belgium

The Statement of Fitness for Work Form is a mandatory document in the Belgian employment system, required whenever an employee is unable to work due to illness or injury. This standardized form, designed to comply with Belgian labor law and social security regulations, serves multiple purposes: it justifies the employee's absence, initiates sick pay procedures, and provides guidance on work capacity. Medical professionals must complete this form following an examination, including specific details about the incapacity period and any possible workplace accommodations. The document plays a crucial role in Belgium's social security system, enabling coordination between healthcare providers, employers, and social security institutions while protecting the employee's medical privacy rights. It forms the basis for calculating guaranteed salary periods and social security benefits, making it an essential document for both employment and social security administration.

1. Patient Information: Basic identification details including name, national registry number, and contact information

2. Medical Professional Details: Name, RIZIV/INAMI number (Belgian healthcare provider identification), and contact information of the certifying doctor

3. Incapacity Period: Start and end date of the work incapacity period, including specification if the end date is confirmed or provisional

4. Nature of Incapacity: Indication of whether this is an initial period of incapacity or an extension of an existing period

5. Work Capacity Assessment: Declaration of whether the patient is totally unable to work or capable of adapted work

6. Diagnosis Code: Standardized medical code for the condition (for social security purposes only, not shared with employer)

7. Authentication: Date of examination, doctor's signature, and official stamp