Back to Work Questionnaire After Sickness

  • Back to Work Questionnaire After Sickness

    This form is designed to help support your return to work following a period of sickness. The information you provide will help us ensure that you are fit to return and identify any adjustments that may be necessary to support you.

  • Employee Information

  • Date of Return to Work:
     - -

  • Sickness Details

  • When did the sickness begin?
     - -
  • Did you provide a medical certificate or doctor's note?

  • Health and Recovery

  • Are you fully recovered and fit to return to work?
  • Have you received any medical advice or treatment regarding your condition?
  • Do you need any additional support or adjustments to help you return to work?
  • Are you currently taking any medication that may affect your work?

  • Work Impact and Adjustments

  • Do you feel able to perform all your usual work duties?
  • Do you require any temporary or permanent adjustments to your work environment or duties?
  • Would you like to discuss any further health-related issues or support options with your manager or HR?

  • Manager's Section (To be completed by the line manager)

  • Has the employee been referred to Occupational Health (if applicable)?
  • Are there any agreed adjustments or accommodations?

  • Employee Declaration

    I confirm that the information provided above is accurate and complete to the best of my knowledge.
  • Date Signed
     - -

  • Manager Declaration

    I confirm that I have discussed the contents of this form with the employee and agreed on any necessary next steps.
  • Date Signed
     - -
  • Should be Empty: