Return to Work Form
Please fill out the employee's return details, absence reasons, and certification information.
Employee name
*
First Name
Last Name
Job title
*
Line manager
*
Date of return to work interview
*
-
Month
-
Day
Year
Date
Date absence started
*
-
Month
-
Day
Year
Date
Date returned to work
*
-
Month
-
Day
Year
Date
Total calendar days absent
*
Total working days absent
*
Reason given for sickness absence
*
Was this absence related to an accident at work?
*
Yes
No
Was this absence related to a disability or long-term health condition?
*
Yes
No
Was this absence related to pregnancy or maternity?
*
Yes
No
Was this absence related to workplace stress or work-related issues?
*
Yes
No
Details, if applicable
Self-certification completed?
*
Yes
No
Not applicable
Fit note provided?
*
Yes
No
Not applicable
Fit note dates
Any recommendations on fit note?
Yes
No
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