Fitness to Return to Work
Name
*
First Name
Last Name
Are you fit to return to work?
*
Please Select
Yes
No
Are you taking any medication that will affect your work?
*
Are there any adjustments you require to return to work?
*
Signature
*
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Manager to complete:
Meeting type
*
Meeting date and time
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
*
Hour Minutes
AM
PM
AM/PM Option
Are they fit to return to work?
*
Please Select
Yes
No
Comments
Manager Name
*
First Name
Last Name
Manager Signature
*
Continue
Continue
Should be Empty: