GCS HR - Return to Work Form

• Document No.

• RTW Employee

• Payroll Number

• Site

• Conducted on

  Date

• Prepared by

• Location
  Address

Return to Work

• Date of First Day of Abscence

  Date

• Date of Return from Abscence

  Date

• Reason for Absence

• Medical Certificate Supplied/Needed

  Yes

  No

• Did you Report your Abscence? To whom?

  Yes

  No

  N/A

• Does this absence relate to any previous time taken of work? Details?

  Yes

  No

  N/A

• Is there any additional information you think we should know about?

• DECLARATION
  The information given above is to the best of my knowledge complete and factual. I understand that any false information may be subject to disciplinary action.

• Employee

  Sign

• GCS Management

  Sign

• Action Required

  Yes

  No