Return to Work Details

Employee Details

This form must be completed after any period of absence, other than holiday, to cover all periods of sickness from the first to the seventh calendar day inclusive.

Job Title

Employee Number


Contact Number

Name of Line Manager

Date of meeting
Day/s of Absence (to be completed by your line manager with you)
First Date of Absence
Last Date of Absence
Date returned to Work

Total number of Working Days Absent

Reason for Absence (please specify the nature of your illness/symptoms)

Steps for the Involved Worker

Prepare sufficient supply (must last at least for 14 days after last exposure) of face mask to be worn at all times while in the workplace

Employers can issue face masks or can approve employees’ supplied cloth face coverings in the event of shortages.

Maintain 6 feet and practice social distancing as work duties permit in the workplace

Avoid sharing headsets or objects used near face

Avoid congregating in the break room or other crowded places

Steps for the Employer

Measure the employee’s temperature and assess symptoms prior to them starting work

Clean and disinfect all areas such as offices, bathrooms, common areas, shared electronic equipment routinely

Test the use of face masks to ensure they do not interfere with workflow.

Increase air exchange in the building

Increase the frequency of cleaning commonly touched surfaces

Create a plan of staggered breaks and communications that discourage congregation in the break room and sharing of utensils

Employee Signature
Manager Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.