Return to work assessment

• Name of Person Returning to Work

• Site

• Assessment conducted on

  Date

• Assessment completed by

• Location of Assessment

• Name of Person Returning to Work

• Occupation

• Date of birth

• Project

• Location

• Duration of absence

• Nature of the injury/illness or circumstances that rendered the person unfit for work

• Has a fit note been obtained from the doctor?

  Yes

  No

• Is occupational health advice required? If ‘Yes’ state advice given

  Yes

  No

• Advice given

• Is any medication being taken? If "Yes" state details

  Yes

  No

• Medication

• Proposed working hours (using 24‑hour clock)

• Nature of work to be undertaken

• Specific work that must not be undertaken

• Specific hazards/risk identified

• Control measures required

• Note: the health and safety briefing must include the:
  risks identified by the assessment
  preventative/protective measures required to ensure the employee’s health and safety
  duties/tasks that are forbidden
  emergency procedures and how they will be implemented
  first-aid arrangements

• Is safety induction required due to long-term absence/significant change in site conditions?

  Yes

  No

• Safety induction carried out by

• Date of induction

  Date

• Details of induction

Acknowledgement

• Assessment briefing completed by

• Position

• Signature

  Sign

• Date

  Date

• Confirmation . I have been briefed on this assessment and agree with the content

• Name

• Position

• Signature

  Sign

• Date

  Date

• Does this assessment require further review?

  Yes

  No

• Agreed risk assessment review date

  Date