ABSENCE & ILLNESS RETURN TO WORK FORM
Absence & Illness Return To Work Form
|TO BE COMPLETD BY MANAGER/DIRECTOR WITH EMPLOYEE IMMEDIATELY FOLLOWING |
|EMPLOYEES RETURN TO WORK |
|Date of Interview | |Interview conducted by | |
| | | | | | |
|First day absent | |Last day absent | |Date & Time | |
| | | | | | |
|No of working days absent| |No of days absent in last| |Absence notified by: | |
| | |12 months | | | |
|Further details about nature of illness/injury/absence. |
|Do you feel you are fit to return to | |If you are returning prior to the | |
|work? | |expiry of a current certificate, do | |
| | |you have the Doctor’s agreement? | |
|Did you consult your GP (or hospital doctor) or other suitably qualified health practitioner (e.g. nurse at GP surgery, hospital, pharmacist) during this |
|absence? |
|If No, why not? If yes, who did you consult and what advice did they give? |
| |
|Are you taking any medication? | |Is there is anything regarding your | |
| | |medication we should be aware of? | |
|Have you been advised to avoid driving/using machinery? |
|If yes, give details. |
|Do you have any recurring or underlying problems with your health? |
|If yes, please explain. |
| |
|How would you describe your general state of health? |
| |
|Is the cause of your absence likely to recur? Are you experiencing any family or personal problems? (detail |
|If applicable) |
| |
| |
|Is there any aspect of your job which you feel is contributing to your health problems (or which potentially could do?) Do you have suggestions of |
|anything we could do to help you to overcome this? |
| |
|List agreed action points and timescales: |
| |
|Optional questions - only discuss where relevant |
|You have a poor attendance record, characterised by short periods of self certified absence for minor unrelated illness or injury. How do you explain |
|this? |
| |
|What action are you going to take to reduce your level of sickness? |
|Would you have any objection if we wanted to contact your doctor for a medial report? |
|I confirm this is an accurate record of the discussion with the Manager and declare myself fit for work. |
| |
|Employee’s signature Date |
|I confirm that I have discussed my above recommendation with the employee. |
| |
|Signed (Manager) Date |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- instructions request for leave absence report
- reporting absences on behalf of the employee csusb
- absence illness return to work form
- department of human resources
- employee attendance policy workable
- sickness absence notification form york
- ona hospital professional responsibility workload report form
- return to work form coventry
- absence request form
- ocu attendance report
Related searches
- printable return to work note
- blank return to work form
- return to work form template
- free return to work form
- medical return to work letter
- return to work form printable
- return to work form
- physician return to work form
- medical return to work form
- sample return to work letter
- return to work letter
- return to work letter from doctor