Title Page
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Name
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Department
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Conducted on
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File Number
Return to Work Details
Employee Details
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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.
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Job Title
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Employee Number
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Department
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Contact Number
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Name of Line Manager
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Date of meeting
Day/s of Absence (to be completed by your line manager with you)
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First Date of Absence
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Last Date of Absence
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Date returned to Work
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Total number of Working Days Absent
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Reason for Absence (please specify the nature of your illness/symptoms)
Steps for the Involved Worker
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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
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Employers can issue face masks or can approve employees’ supplied cloth face coverings in the event of shortages.
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Maintain 6 feet and practice social distancing as work duties permit in the workplace
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Avoid sharing headsets or objects used near face
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Avoid congregating in the break room or other crowded places
Steps for the Employer
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Measure the employee’s temperature and assess symptoms prior to them starting work
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Clean and disinfect all areas such as offices, bathrooms, common areas, shared electronic equipment routinely
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Test the use of face masks to ensure they do not interfere with workflow.
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Increase air exchange in the building
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Increase the frequency of cleaning commonly touched surfaces
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Create a plan of staggered breaks and communications that discourage congregation in the break room and sharing of utensils
Sign-Off
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Employee Signature
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Manager Signature