Title Page

  • Name

  • Department

  • Conducted on

  • File Number

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?


  • Action Plan (Agreed adjustments, Review dates and Comments)

  • Employee Signature

  • Manager Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.