Return to Work Form Template

• Conducted on

  Date

Employee Details

• This form must be completed after any period of sick leave. The aim is to answer the question: "How can we help you?".

• Employee Name

• Contact Number

• Name of Team Leader

• The date you notified the Team of the impending Sick Leave

  Date

Day/s of Absence (to be completed by your line manager with you)

• First Date of Absence

  Date

• Last Date of Absence

  Date

• Date returned to Work

  Date

• 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?

  Yes

  No

  N/A

• Did you provide the Doctors note to the Accounts Manager & Team Leader?

Sign-Off

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

• Employee Signature

  Sign

• Team Leader Signature

  Sign