Title Page

  • Document No.

  • Person returning to work

  • Conducted on

  • Manager

Return to work Interview

  • This form must be completed immediately upon employees return to work with their line manager.

Employee Details

  • Name

  • Job Title

Absence Details

  • First date of absence

  • Date of Return

  • No. Of days Absent

  • Who was the absence reported to.

  • Method of informing Manager

  • Date Reported

  • Has employee provided a self certificate or fit note ?

  • Was absence due to illness?

  • Give details

  • Description of symptoms

  • Did employee see a Doctor

  • Details

  • Was this a recurring illness?

  • Is the employee fully recovered?

  • What modifications to their job will be required?

  • Will their symptoms/medication affect their ability to do the job?

Declaration

  • I understand that if I provide inaccurate or false information about my absence I may be subject to disciplinary action and may forfeit my right to sick pay,subject to my service entitlement.

Review by Manager

  • Is any further action required? e.g occupational surveillance or review any patterns of absenteeism

  • Managers Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.