COVID-19 Return to Work Record

• Conducted on

  Date

• Returning employee name:

• Return to work record completed by:

• Location
  Address

COVID-19 Return to Work Induction

• Leave start date

  Date

• Leave end date

  Date

• Reason for absence

  Select COVID-19 Furloughed employee returning to work Other

  • COVID-19 Furloughed employee returning to work
  • Other

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

  Yes

  No

• Please confirm the employees return to work date

  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

  Select 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

  • 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?

  Yes

  No

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

  Yes

  No

  N/A

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

  Yes

  No

• Please confirmed PPE items received by employee

  Select Medical Gloves Hand Wipes Disinfectant Face Shield Face Guards Trauma Aid Dressing Other

  • 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?

  Yes

  No

• Has the employee checked their voicemail and changed their response?

  Yes

  No

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

  Yes

  No

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?

  Yes

  No

• Please specify why and contact HR immediately

• Signature of Manager

  Sign

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

• Date & Time

  Date

• Signature of Manager

  Sign

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

• Date & Time

  Date