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COVID-19 Return to Work Record
COVID-19 Return to Work Record
Beth Reed

COVID-19 Return to Work Record Checklist

FM Return To Work Sample

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Free COVID-19 Return to Work Record Checklist

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COVID-19 Return to Work Induction

COVID-19 Return to Work Induction
Leave start date
Leave end date
Reason for absence
  • COVID-19 Furloughed employee returning to work
  • Other

Has the employee received their letter to confirm a return to work date?

Please confirm the employees return to work date
Please confirm that the employee does not have any of the known commonly associated COVID-19 virus (Coronavirus) symptoms and they are symptom free at this time
  • The employee confirms they do not have a high temperature
  • The employee confirms they do not have new persistent cough
  • The employee has confirmed they are currently symptom free

Please contact HR and confirm your return to work date

COVID-19 Safety Updates

Has the employee been briefed on all COVID-19 updated safety measures?

Has the employee been informed of any client specific COVID-19 safety communications?

Has the employee received all additional COVID-19 PPE applicable to their role?

Please confirmed PPE items received by employee
  • Medical Gloves
  • Hand Wipes
  • Disinfectant
  • Face Shield
  • Face Guards
  • Trauma Aid Dressing
  • Other

Please ensure that the employee has received all the additonal PPE required for COVID-19

Has the employee completed any return to work handover necessary?

Has the employee checked their voicemail and changed their response?

Has the employee removed their 'out of office' response?

Return to work induction declaration & sign off (Manager)

By signing you confirm that the employee has confirmed they have successfully been inducted back to work following COVID-19 furloughing and they are fit to return to work on full duties and compliant to the company's policy on drugs and alcohol. If not confirmed, the reason for this or an alternative proposal must be detailed below and sent to HR for approval.

Does the employee confirm they have received the return to work induction and they can return to work safely?

Please specify why and contact HR immediately

Signature of Manager

A COPY OF THIS 'RETURN TO WORK' FORM MUST BE SENT TO THE EMPLOYEE ON COMPLETION

Date & Time
Signature of Manager

A COPY OF THIS 'RETURN TO WORK' FORM MUST BE SENT TO THE EMPLOYEE ON COMPLETION

Date & Time
COVID-19 Return to Work Record
Beth Reed

COVID-19 Return to Work Record

FM Return To Work Sample

Use this Digital Checklist
Download as PDF
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.

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