Section 1 - Employee Details
Name of Employee
Total number of days absent from work
Reason for Absence
Has a Lateral Flow Test for Covid-19 been carried out in the 24 hours prior to the employee's return to work?
What was the result from the LFT?
Please now carry out a LFT and select the result. Please upload a photo of the completed LFT.
Section 2 - Covid-19
Is the employee's Absence due to COVID-19?
Did the employee call the COVID - 19 help number to advise absence?
Did the employee inform their Manager/Help Desk?
Did we receive a self-isolation note?
How long did the employee self-isolate? No of days?
Was the employee required to self isolate due to individual or family or bubble or track and trace reasons?
Did the employee book a COVID-19 test?
Did the employee send a confirmation receipt that they booked a test 4 hours after advising that they were self-isolating?
Did the employee send results of test?
What was the result of the test?
Was the employee hospitalized as a result of COVID-19?
Did the employee advise who they where working with on their last shift before they self-isolated?
Is there anything that we should be aware of due to the employee's absence due to COVID-19? If yes, please note below and ask employee to self-refer to their Doctor for further information.
Section 3 - Injury at Work
Is Absence due to an Injury at Work?
If Accident at Work, has an Accident Report been completed?
If Accident at Work, has Health & Safety been advised?
Section 4 - Absence Certification
If absence reason is Covid-19 ONLY, select "NO" to the below question.
Was the employee's period of absence over three days?
Self-Certification (SSP) provided?
Please upload a copy of the SSP form.
The Government SSP form can be downloaded from the link below.
Please download SSP form from the link below, complete and insert a photograph.
Has GP Fit Note been provided (for absences of 7 continuous days)?
Section 5 - GP Consultation / OH Referral
Did the Employee consult their GP?
Did the GP make any recommendations on a Med 3 as to a phased RTW/ amended duties/ change to working location or environment/ potential changes to Employee working hours?
Please state below what these recommendations were and whether they are thought to be practicable Required Adjustments.
Did the GP recommend on the Med 3 that the Employee should be seen by an Occupational Health Specialist?
Do you think that the employee should be referred to Occupational Health?
Does the Employee have any type of disability or condition that they would like to make us aware of?
Did the Employee indicate that factors at work may have caused or contributed to the Absence?
Please explain below & discuss what action is to be taken to support the Employee
Section 6 - Absence Notification
Did the employee properly notify the Employer of their Absence?
Please confirm you have re-briefed the employee on the absence notification procedure.
Is the Absence part of an overall pattern?
Establish underlying reasons/ explain your observations of a pattern & allow the Employee the opportunity to explain:
Please indicate whether attendance levels should be formally escalated to HR
Section 7 - Close
Any further comments from the manager: