Title Page

  • Employee Name.

  • Conducted on

  • Manager Conducting the Interview

Section 1: Absence Details.

Return to work Interview

  • The return to work interview form is designed as a guide for the line manager when meeting with employees on their return to work from sickness or following incidents/accidents etc. The meeting should be formal, polite and relaxed with the manage encouraging discussion and listening as much as talking.

Employee Details

  • Which NJS Company Does the Individual Work For?

  • Job Title or Role

  • Home Address.

  • Date of Birth (dd/mm/yyyy)

  • Employees Photo

Absence Details

  • First date of absence

  • Date of Return

  • Number of days Absent from Work

  • Is the absence reportable under RIDDOR?

  • Has a report been submitted to the HSE?

  • Why has a report not been submitted?

  • Who was the absence reported to.

  • Method of informing Manager

  • Date Reported

  • Has the employee provided a self certificate or fit note ?

  • Take a copy of the form

  • Was absence due to illness?

  • Give details

  • Did the employee see a Doctor

  • Details

  • Was this a recurring illness?

  • Was the absence due to an injury at work?

  • Provide details of the injury

  • Is the employee able to return to their normal duties?

  • 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, or other benefits subject to my service entitlement.

Review by Manager

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

  • If yes, provide further details.

  • Managers Name

  • 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.