Return to Work Form - Maternity Leave
This form is to record return to work information and is to be completed by you (the employee) on the first day of return to work and countersigned by your Manager following Maternity Leave.
Absence Details
To be completed by manager
Name
*
First Name
Last Name
Job Title
*
Return to Work Interview Date
*
-
Day
-
Month
Year
Date
Return to Work Interview
How are you feeling? Do you feel that you are able to carry out your normal hours and duties? If no, what duties are you able to undertake?
*
If vomiting/diarrhea, have you been free from ALL symptoms for atleast 24 hours?
*
Yes
No
Are you able to perform all the functions of your job role?
*
Yes
No
Have you had any health problems whilst on maternity leave that is still causing concern?
*
Yes
No
Are there any adjustments in the workplace required?
*
Yes
No
If yes, please discuss..
Are you on any medication which may put you at work at 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?
*
Are you fit to return to work?
*
Yes
No
To be completed by manager
Has the necessary medical certification been provided?
*
Discuss any updates/changes within the workplace during absence
Does the employee require refresher training?
*
Yes
No
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: