Return to Work (Self Illness and Injury Reporting)

Return to Work

(Self Illness and Injury Reporting)
Name:*
Date Submitted:*

MonthDayYear
Date
Email*
example@example.com
First Day Away:*

MonthDayYear
Date
Number of Days Away:*
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:*

Illness or Sickness (including headache, runny nose, sore throat, muscles aches and pains, cramps, gastrointestinal issues) for yourself.Vacation or business travelInjury at Home or other Non-Work related Injury
What were the Symptoms?*

Fever (>100.4°F or 38°C)*Subjective Fever (feel feverish)*CoughShortness of BreathSneezingSore ThroatRunny NoseDiarrheaVomitingAllergiesHeadacheGeneral Aches/PainFatigue/WeaknessChillsOther
First Day Sick:*

MonthDayYear
Date
Last Day Sick:*

MonthDayYear
Date
Details (if necessary):
Test for COVID-19 if symptoms are related and last for more than 48 hours
Have you had COVID-19 testing done?*

No testing was doneI have been tested and the result was negativeI have been tested and the result was positive
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.*

I have no symptoms nowFever (>100.4°F or 38°C)*Subjective Fever (feel feverish)*CoughShortness of BreathSneezingSore ThroatRunny NoseDiarrheaVomitingAllergiesHeadacheFatigue/WeaknessGeneral Aches/PainOther
Health Declaration*

I confirm that I no longer have any active symptoms and I have met all of BC Health’s requirements to be able to return to work.
How did you come in contact with a potential COVID-19 case? Please provide details.*
Did they have COVID-19 testing done?*

No testing was doneThey have been tested and the result was negativeThey have been tested and the result was positive
How many days have they been self-isolated/quarantined?*
Have you had COVID-19 testing done?2*

No testing was doneI have been tested and the result was negativeI have been tested and the result was positive
How many days have you self-isolated/quarantined?*
What symptoms do you currently have?*

I have no symptomsFever (>100.4°F or 38°C)*Subjective Fever (feel feverish)*CoughShortness of BreathSneezingSore ThroatRunny NoseDiarrheaVomitingAllergiesHeadache General Aches/PainFatigue/WeaknessOther
Select one:*

Travel was involved during my vacationNo travel was involved during my vacationReturning from Business related travel
Health Declaration*

I confirm that I have been isolating at home. I have met all of BC Health’s requirements to be able to return to work.
Where did you go?*
For how long?*
What was your means of transportation?*

PlaneBoatBusTrain
While you've been gone, have you suffered from sickness, vomiting, diarrhea or any stomach disorder?*

YesNo
Have you had any “flu like” symptoms?*

YesNo
Have you suffered from any infectious conditions of the skin, nose, throat, ears or eyes?*

YesNo
Have you been in contact with anyone with typhoid, typhus, paratyphoid, and gastro-enteritis or other foodborne illness?*

YesNo
Do you have any skin conditions affecting your arms or face?*

YesNo
Do you have any infected wounds at present?*

YesNo
Do you have any current physical symptoms?*

I have no current physical symptomsFever (>100.4°F or 38°C)*Subjective Fever (feel feverish)*CoughShortness of BreathSneezingSore ThroatRunny NoseDiarrheaVomitingAllergiesHeadache General Aches/PainFatigue/WeaknessOther
Comments
Health Declaration*

I confirm that I am feeling healthy after my return from vacation/travel (If Required). I have met all of BC Health’s requirements to be able to return to work.
How did you hurt yourself?*
Do you have any open wounds?*

YesNo
Describe the open wound:*
What was reason for your absence?*
Can you return to your regular duties?*

Yes, I acknowledge that I do not have any illness and I have fully recovered from the injury I previously sustained. I am fit to return to work to perform the full duties associated with my position. I do not require further modified dutiesNo, I require modified duties (if available). I understand that the modified duties will be approved by HR. If I qualified for modified duties, I am expected to show for my regular shifts.
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*
Return to Food Handling?
Modified Duties/ PPE:

MaskIsolated WorkOther
Senior Management comments (if necessary):
Status
Status Approved
Document Reference: Return to Work HRR 031

Owned By: President Authorized By: Director of Operations
Should be Empty: