Clubland Return to Work Form Template

• Name

• Job Role

• Conducted on

  Date

• File Number

Employee Details

• This form must be completed after any period of absence, other than holiday, to cover all periods of sickness from the first to the seventh calendar day inclusive.

• Job Title

• Contact Number

• Name of Supervisor

• Date of meeting

  Date

Day/s of Absence (to be completed by your line manager with you)

• First Date of Absence

  Date

• Last Date of Absence

  Date

• Date returned to Work

  Date

• Total number of Working Days Absent

• Reason for Absence (please specify the nature of your illness/symptoms)

Contacting the company

• Did you properly notify the employer of your absence?

  Yes

  No

  N/A

• Who did you speak to?

• When did you contact the company?

  Date

Previous sickness absence (to be completed by your line manager if applicable)

• Previous Absences - List each separate occasion, with number of days and reason.

• Total number of days absent in the last 6 months:

• Total number of days absent in the last 12 months :

• Are you aware of the absence reporting procedures?

  Yes

  No

  N/A

Sign-Off

• Action Plan (Agreed adjustments, Review dates and Comments)

• Employee Signature

  Sign

• Manager Signature

  Sign