Title Page
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Site conducted
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Conducted on
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Prepared by
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BACK TO WORK
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Employees’ Name
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Reason for Absence
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First date of absence
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Last date of absence
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Total working days
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Date Return to Work Interview Completed
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Absence Paid
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Currently in probation
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Doctors note provided:
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I can confirm the above dates are accurate: (employee)
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To be completed if the absence was due to sickness:
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Reason for the sickness:
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Matters discussed:
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Confirm the following has been done
Bought up to date on company briefings
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Offered support if necessary
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Checked they have no questions
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Date:
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Signed: (Employee)
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Signed: ( Employer)
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Date:
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Outcome:
