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
Full Name:
Job Title:
Line Manager:
Please Select
Nadine Gwazai
Mutsa Gwedegwe
Chiletso Shati
Date of Return to Work:
-
Month
-
Day
Year
Date
Sickness Details
What was the reason for your absence?
Please Select
Illness
Injury
Medical Procedure
Other
Please specify the selected reason.
When did the sickness begin?
-
Month
-
Day
Year
Date
Did you provide a medical certificate or doctor's note?
Yes
No
Health and Recovery
Are you fully recovered and fit to return to work?
Yes
No
If you selected "No" please specify
Have you received any medical advice or treatment regarding your condition?
Yes
No
If you selected "Yes" please specify
Do you need any additional support or adjustments to help you return to work?
Yes
No
If you selected "Yes" please provide details
Are you currently taking any medication that may affect your work?
Yes
No
If you selected "Yes" please specify
Work Impact and Adjustments
Do you feel able to perform all your usual work duties?
Yes
No
If you selected "No" please specify which duties may be affected
Do you require any temporary or permanent adjustments to your work environment or duties?
Yes
No
If you selected "Yes" please specify
Would you like to discuss any further health-related issues or support options with your manager or HR?
Yes
No
Manager's Section (To be completed by the line manager)
Has the employee been referred to Occupational Health (if applicable)?
Yes
No
Are there any agreed adjustments or accommodations?
Yes
No
If you selected "Yes" please specify
Summary of discussion and any actions agreed:
Employee Declaration
I confirm that the information provided above is accurate and complete to the best of my knowledge.
Sign Your Full Name Here
Date Signed
-
Month
-
Day
Year
Date
Manager Declaration
I confirm that I have discussed the contents of this form with the employee and agreed on any necessary next steps.
Sign Your Full Name Here
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: