• Return to Work

    Return to Work

    (Self Illness and Injury Reporting)
  • Date Submitted:*
     / /
    2 digit month, 2 digit day, 4 digit year
  • First Day Away:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • STOP! NOTE:

    You must discuss this with a member of Management before starting work.

    This form must be completed if you are:

    ·         Returning after any absence due to illness, including during a weekend

    ·         Returning from vacation or business travel

    ·         Returning to work after an injury that occured outside of the workplace

  • Reason for Absence:*
  • What were the Symptoms?*

  • First Day Sick:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last Day Sick:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you had COVID-19 testing done?*
  • What symptoms do you currently have? Note: If you have mild symptoms while recovering from illness and plan to come to work, you are required to wear a face mask.*

  • Did they have COVID-19 testing done?*
  • Have you had COVID-19 testing done?2*
  • What symptoms do you currently have?*

  • Select one:*
  • What was your means of transportation?*
  • While you've been gone, have you suffered from sickness, vomiting, diarrhea or any stomach disorder?*
  • Have you had any “flu like” symptoms?*
  • Have you suffered from any infectious conditions of the skin, nose, throat, ears or eyes?*
  • Have you been in contact with anyone with typhoid, typhus, paratyphoid, and gastro-enteritis or other foodborne illness?*
  • Do you have any skin conditions affecting your arms or face?*
  • Do you have any infected wounds at present?*
  • Do you have any current physical symptoms?*

  • Do you have any open wounds?*
  • Can you return to your regular duties?*

  • When returning to work after an injury, if modified duties are required, a doctor's note must be provided, noting any physical limitations and the length of time duties need to be modified. The employee is responsible for any fees associated with the doctors note. 

  • Signature*
  • Modified Duties/ PPE:

  • Document Reference: Return to Work HRR 031                                              

    Owned By: President           Authorized By: Director of Operations

  • Should be Empty: