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)
Contacting the company
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Did you properly notify the employer of your absence?
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Who did you speak to?
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When did you contact the company?
Previous sickness absence (to be completed by your line manager if applicable)
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Previous Absences - List each separate occasion, with number of days and reason.
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Total number of days absent in the last 6 months:
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Total number of days absent in the last 12 months :
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Are you aware of the absence reporting procedures?
Sign-Off
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Action Plan (Agreed adjustments, Review dates and Comments)
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Employee Signature
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Manager Signature
