Return to work interview form V1

• Document No. - operatives name

• Employee name

• Conducted on

  Date

• Prepared by

• Location
  Address

For completion by the line manager

• Job title

• Department

• First day of absence

  Date

• Date returned to work

  Date

• Total days absent from work

• Reason given for absence

• Date and time of notification

  Date

• Method of notification

  Select Phone call Email Text Not notified

  • Phone call
  • Email
  • Text
  • Not notified

• Expected date of return

  Date

• Is absence due to an injury at work

  Yes

  No

  N/A

• If accident at work, has an accident report been completed

  Yes

  No

  N/A

RTW discussion record notes - for completion by the line manager (as appropriate)

• Discussion record

I confirm that the aforementioned notes represent an accurate record of the issues discussed and the actions undertaken/ recommended

• Manager

  Sign

• Select date

  Date

For completion by individual returning to work

• Date you became unfit to work

  Date

• Date on which you became fit to work

  Date

• Actual date of return to work

  Date

• What was the nature of your sickness

• Have you seen a doctor

• Have you seen a dentist

• Have you been to hospital

• Are medical certificates attached

  Yes

  No

  N/A

I confirm that the attached sickness summary is an accurate record of my absence history and that the interview notes are an accurate record of the issues discussed. In addition, I wish to comment as follows

• Employee comments

I declare that the above statement is accurate and understand that to give false or misleading information may result in dismissal

• Employee

  Sign

• Select date

  Date

DATA PROTECTION The company processes the information provided on this form and on medical certificates for the purposes of meeting it's legal obligations. In particular, individual data are disclosed to line managers for the purpose of responding appropriate land fairly to individuals overall level of sickness absence and for the appropriate management of their safety at work.