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)

Contacting the company

Did you properly notify the employer of your absence?

Who did you speak to?

When did you contact the company?
Previous sickness absence (to be completed by your line manager if applicable)

Previous Absences - List each separate occasion, with number of days and reason.

Total number of days absent in the last 6 months:

Total number of days absent in the last 12 months :

Are you aware of the absence reporting procedures?

Sign-Off

Action Plan (Agreed adjustments, Review dates and Comments)

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.