Return to Work Form (BCS)

• Name of employee

• Location
  Address

• Conducted on

  Date
Previous Sickness/Absence record (in last 12 months)

• Add Dates from and to:

• Reasons for Absence

• No. of previous days absent (not including the most recent, that this RTW applies to)

• First Day of Absence

  Date

• Last Day of Absence

  Date

• No. of Days Absent

• Reason given by employee for absence

• Details of treatment received

• Was absence related to a previous absence?

• Did employee seek medical attention during this period of absence?

  Yes

  No

• Please provide details including date(s) & location(s)?

• Please give reason why medical attention was not sought.

Health Screening Questionnaire

• Prior to/during the absence has the employee been involved in overseas travel?

  Yes

  No

• If yes to the above, state countries visited, dates and length of stay

• Is the reason for the absence likely to be ongoing/recurring?

  Yes

  No

• If yes, please give details

• Has the employee been absent for this reason before?

  Yes

  No

• Please give details, Dates, Reason and Who reported to?

• Was the absence due to an accident at work?

  Yes

  No

• Was this accident/injury recorded in an Accident book/form?

  Yes

  No

• Why not?

• If the absence exceeded 7 days, has a medical certificate been submitted?

  Yes

  No

  N/A

• Please explain why not

• Is this accident a result of a sporting activity?

  Yes

  No

• Please provide details

• Did the employee comply with absence reporting procedures?

  Yes

  No

• Please provide reason

• Did the employee "PHONE" in him/herself within the required time? (Text messages not accepted)

  Yes

  No

• Pease explain reason why not

• If the absence was on-going, did they keep in regular contact with the company?

  Yes

  No

• Pease explain reason why not

• Did the employee notify the company of a return to work date, prior to returning?

  Yes

  No

• Pease explain reason why not

• Did the employee submit a medical certificate if sickness absence exceeded 7 calendar days?

  Yes

  No

  N/A

• Pease explain reason why not

• Is a pattern developing or concern of frequency, that requires further action?

  Yes

  No

• ROC: Carry out ROC meeting in relation to attendance/absence.

• Create Action: Arrange follow up meeting/Notify Head Office

Should not be paid due to:

• Failure to follow notification procedures

• Other reason - please specify

• undefined

Employee Declaration

• I have checked the above contents and declare that the details I have provided are true and accurate. I understand that to give false or misleading information will result in summary dismissal. I agree to Bulloughs Cleaning Services Ltd holding this information on my personal file and to a summary of this information being held for monitoring and reporting purposes.

• Employee Signature

  Sign

• Manager/Supervisor Signature

  Sign