Return to Work Form
This form is torecord sickness absence information and is to be completed by you (theemployee) on the first day of return to work and countersigned by your Manager.It must be completed for all periods of sickness absence. If you leave work early on a day as a result ofsickness, you should record the time you left in the section headed “date onwhich you first became unfit for work”. If youare absent due to illness for more than seven consecutive calendar days, youmust also provide a doctor’s certificate. This form must be completed after anyabsence other than holiday. Once completed,this form will be placed on your personnel file, a separate record will also bekept of your attendance record.
Absence Details
To be completed by manager
Name
*
First Name
Last Name
Job Title
*
Return to Work Interview Date
*
-
Day
-
Month
Year
Date
Dates of Sick Absences
*
Total number of working days absent during this sickness period
*
Reason for Absence
*
Return to Work Interview
How are you feeling now? Do you feel that you are able to carry out your normal hours and duties? If no, what duties are you able to undertake?
*
Did you seek any medical attention for your sick absence?
*
Do you require any further medical attention for your sick absence?
*
Was your absence work related?
*
Was your absence pregnancy related?
*
Are you on any medication which may put you at work at work?
*
Are you fit and/or certified to return to work?
*
Is there anything we can do to support you upon your return to work?
*
Is there any issues that we should be aware of while you were absent or any issues you wish to raise?
*
Do you have any underlying health problems which may contribute towards your recent illness and may result in further absences?
*
To be completed by manager
Did the employee follow the correct sick absences reporting procedure?
*
Yes
No
Total sick days in the past 12 months (including this absence period)
*
Has the necessary medical certification been provided?
*
If work related, has an incident form been completed?
*
Any other comments, recommendations/actions required?
*
Employee Confirmation
I declare that the information I have given on this form is true and I confirm that I am now fit to resume work. I understand that it is a serious disciplinary offence to provide false information on this form.
Signature
*
Date
*
-
Day
-
Month
Year
Date
Manager Confirmation
Verified and accepted by the management.
Signature
*
Date
*
-
Day
-
Month
Year
Date
Submit
Should be Empty: