Return To Work Form
This form must be completed after any period of Absence.
Name
*
First Name
Last Name
Department
*
Please Select
Business Support
Finance
HCC
HR
IT
Maintenance Admin
Maintenance Engineers
Management
Projects
Managers Name
*
First Name
Last Name
Managers Email
*
Please ensure the email address is correct
First Date of Absence
*
-
Day
-
Month
Year
Date
Return to Work Date
*
-
Day
-
Month
Year
Date
Reason for the Absence?
*
Is this absence likely to reoccur?
Yes
No
Is this absence linked to an ongoing medical condition?
Yes
No
Is this a work related illness?
*
Yes
No
Have you consulted your GP?
*
Yes
No
Have you been prescribed any medication?
*
Yes
No
I confirm I am fit to return to work
*
Yes
Employee Signature
*
Please verify that you are human
*
Submit
Should be Empty: