CPW296 Return To Work

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Name:

  Select Zahid Ilyas Ismail Mayat Daniel Green Serkan Gurbuz Kamran Khan Louise Taylor Khalil Ahmed Alia Begum Hannah Jessop Amy Waller

  • Zahid Ilyas
  • Ismail Mayat
  • Daniel Green
  • Serkan Gurbuz
  • Kamran Khan
  • Louise Taylor
  • Khalil Ahmed
  • Alia Begum
  • Hannah Jessop
  • Amy Waller

• Job Title:

  Branch Manager

  Assistant Manager

  Customer Consltant

• Department:

  Retail Store

  Call Centre

  Warehouse

• Name Of Line Manager:

  Angela Gillespie

  Zahid Ilyas

  Ismail Mayat

• Employee Payroll Number:

• Today's Date

  Date

Current Sickness / Absence

• Date and Time Of Meeting:

  Date

• Absence Start Date:

  Date

• Absence End Date:

  Date

• No Of Days Absence:

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 more then 3 weeks

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • more then 3 weeks

• Confirm Reason For Absence:

• Did you seek medical advise?

  Yes

  No

  N/A

• Fit To Work Note Recieved?

  Yes

  No

  N/A

• No of days that will be paid.

• No of days that will not be paid.

In order to establish how you are and if there are any underlying issues or concerns with regards to your health

• How are you feeling now that you have come back to work?

• What medical advice have you received?

• Are you still undergoing medical treatment? If so, what is it? Are there any potential side effects?

• Is there anything else that you feel may be contributing or has contributed to you sickness absence?

• What additional support do you need from me or the company? E.g. referral to occupational health/employee support programme, a desk assessment, adjustments to your equipment or working area,

• Previous Sickness absence ?

• Total no of days absent?

  Select 0 1 2 3 4 5 6 7 8 9

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9

• Within last 6months

  Select 0 1 2 3 4 5 6 7 8 9

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9

• Are you aware of the absence reporting procedure?

  Yes

  No

  N/A

• Employee signature

  Sign

• Line manager signature

  Sign