Return to Work Discussion: Record Form - ExcelSHE
York St John University
Return to Work Discussion: Record Form
(To be retained within the department by the Line Manager as a confidential record)
|1.Name Of Employee | |
|Job Title: | |
|Date of Return to Work Discussion | |
|Dates of this Absence |From: |To: |Total number of working days on this occasion: |
|Cumulative total to date (12 month rolling|Number of cumulative days: |Number of cumulative occasions: |
| | | |
|cycle) | | |
|Trigger Points |4 spells in 12 months |2 consecutive weeks |
| |Y / N |Y / N |
|2. Reason For this Absence |
| |
| |
| |
|3. Was the absence related to work i.e. accident or |Yes |No |
|illness | | |
|If Yes was it reported? |Yes |Date: |No |
|4. Is the employee fit to return to work? |4a. Is the absence related to a disability? |
|Yes / No |Yes / No |
|5. Are there any adjustments to workplace/ hours / | |
|duties to be made that could facilitate return to | |
|work or eliminate absence? | |
| | |
|6. Details of Support offered | |
| | |
| | |
| | |
|7. Details of follow up action |Details |
|No follow up | | |
|For further informal review | | |
|Targets Agreed | | |
|Refer to HR for formal review | | |
|Refer to Occupational Health | | |
|8. Line Manager’s Name | |
| Signature | |
| Employee Name | |
| Signature | |
| Date | |
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