Return to work interview
Connection Flooring Ltd. Henson Close, South Church Enterprise Park, DL14 6WA
Return to work interview
Employee Name
*
Job title and location
Job Title/Location
*
Please Select
Head office, Office Staff
Retail Stores
Driver/Depot
Warehouse
Person filling out this form
*
Your line manager
*
First date of absence
*
-
Day
-
Month
Year
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Date absence ended
*
-
Day
-
Month
Year
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Reason for absence
*
Did you correctly notify the employer
*
Yes
No
Did you consult a GP
*
Yes
No
Any evidence provided?
*
Please Select
Yes
No
Was your absence work related
*
Yes
No
If your previous answer was (Yes) give details
Are you currently taking any medication?
Yes
No
If your previous answer was yes please list all Medications.
Please list medication you are currently taking.
Do you have any type of disability
*
Yes
No
Do you believe you are now fit for work
*
Yes
No
Has a Phased Return been agreed by HR?
Yes
No
If the answer above is yes, please give details of the Phased return.
HR recommendations
E Signature
*
By ticking this box you agree that to the best of your ability you have given true and correct answers and that you are fit for work
Employee Signature
*
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