Title Page

  • Name

  • Department

  • Conducted on

  • File Number

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

  • Department

  • 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

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.