Return to Work 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.
Name of Line Manager
Total number of Working Days Absent
Reason for Absence (please specify the nature of your illness/symptoms)
Did you properly notify the employer of your absence?
Who did you speak to?
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?
Action Plan (Agreed adjustments, Review dates and Comments)