Fitness For Duty Referral

Fitness for Duty Referral and Evaluation Protocol

Dr. Long is a forensic psychologist who specializes in conducting fitness for duty evaluations (FFDEs) for a diverse range of industries.

Licensed through PSYPACT, Dr. Long is able to conduct these evaluations virtually in 41 states. Alternatively, face-to-face evaluations can be arranged at our Charlotte office. To initiate an FFDE or schedule a consultation with Dr. Long, please complete this referral form.

You may review Dr. Long's CV here and access her LinkedIn profile through this link.

For employers seeking guidance on initiating these evaluations, we recommend reviewing our helpful guide, which can be accessed here.

We understand the time-sensitive nature of these evaluations and strive to schedule them within a week of receiving the referral. Typically, the report will be provided within 12 to 14 days of the assessment. An expedited turnaround is available for an additional fee. The flat rate for these evaluations is $1,500, which covers all aspects of the evaluation and report.

After you complete the referral form, Dr. Long will review your information and contact you to schedule and arrange payment.

This referral portal is secured with 256-bit SSL encryption, ensuring that all submitted data is automatically encrypted while in transit between your submissions and our servers.
Organization/Company Name*
Company Website*
Company's Representative Name*

First NameLast Name
Company's Representative Email *
example@example.com
Phone Number*
Please enter a valid phone number.
Employee's First Name Only.*
Employee's Last Name Only.*
Employee's Birthdate *

MonthDayYear
Date
Employee's Age*
Employee's Job Title*
Hire Date *

MonthDayYear
Date
Please provide a brief summary of the employee's job description, including their primary duties, responsibilities, and any essential functions of their role. This summary will assist the evaluator in understanding the context in which the employee's fitness for duty is being assessed. If you prefer, you may upload the employee's existing job description documents in the supporting documentation section at the end of this form.*
When referring an employee for a fitness for duty evaluation, it's essential to provide clear and specific reasons for the referral. This helps the evaluator understand the context and focus their assessment on the relevant areas of concern. Below, you will find a list of common reasons for workplace evaluation referrals. Please review the list carefully and check all the reasons that are relevant to your referral. If there are any additional reasons not listed, please provide details in the space provided at the end of the form. Your accurate and thorough information will assist the evaluator in conducting a comprehensive assessment and providing appropriate recommendations.

A. Observed decline in work performanceB. Exhibiting unusual or disruptive behavior in the workplaceC. Involved in a workplace accident or safety incidentD. Returning to work after an extended absence due to illness or injuryE. Requesting accommodations for a medical or mental health conditionF. Displaying signs of substance abuse or impairment on the jobG. Experiencing frequent absences or tardiness without explanationH. Showing signs of cognitive impairment or confusionI. Demonstrating poor judgment or decision-making skillsJ. Reported concerns from coworkers or supervisors about the employee's well-beingK. Holding a safety-sensitive position that requires regular evaluationsL. Exhibiting aggressive, threatening, or violent behavior towards othersM. Failing to adhere to company policies or safety protocolsN. Undergoing significant changes in personal life that may impact work performanceO. Displaying physical limitations or discomfort that affect job dutiesP. Returning to work after a leave of absence for mental health reasonsQ. Showing signs of emotional instability or psychological distressR. Requesting a transfer to a position with different physical or mental demandsS. Displaying a pattern of poor interpersonal communication or conflict with othersT. Experiencing a traumatic event, either work-related or personal, that may impact job performanceOther
Please select the employee's current work status:

A. Actively working with no restrictionsB. Actively working with temporary restrictions or accommodationsC. Actively working but on a performance improvement planD. On paid administrative leave pending the evaluation outcomeE. On unpaid administrative leave pending the evaluation outcomeF. On short-term disability leaveG. On long-term disability leaveH. On workers' compensation leave due to a work-related injury or illnessI. On medical leave under the Family and Medical Leave Act (FMLA)J. On personal leave of absenceK. Recently returned to work following a leave of absenceL. Recently transferred to a new position or departmentM. Currently in the process of transitioning back to work after a leaveN. Suspended from work pending the evaluation outcomeO. Terminated from employment but evaluation still requestedP. Resigned from employment but evaluation still requestedOther
Summary of Concerns or Incidents:

(If you prefer, you may upload a summary document in the supporting documentation section at the end of this form.)

Please provide a brief overview of the specific concerns, incidents, or observations that have prompted the need for a fitness-for-duty evaluation. This summary should include relevant details such as dates, descriptions of the events or behaviors, and any immediate actions taken by the company in response to these concerns.

Example: "Over the past three months, the employee has exhibited a pattern of decreased productivity and increased absenteeism. They have missed a total of 12 workdays without prior approval or sufficient explanation. Additionally, on March 15, 2023, the employee was involved in a verbal altercation with a coworker, which resulted in a temporary disruption of the work environment. The employee's supervisor has addressed these concerns with them on two occasions, but no significant improvement has been observed."

Please keep the summary concise while providing enough information for the evaluator to understand the context and nature of the concerns.
Enter Summary of Concerns *
Supporting Documentation:

Please use the document upload feature below to submit any relevant documentation that will provide context and inform the fitness for duty evaluation. You may upload up to 20 files at one time, and all file formats are accepted.

This may include:
- Performance reviews
- Disciplinary records
- Incident reports
- Witness statements
- Job description and essential functions
- Accommodation requests or records
- Leave of absence documentation
- Return-to-work plans or agreements
- Any other pertinent documents related to the reasons for the evaluation referral
File Upload

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