• Employee name

  • Conducted on

  • Document No.

About the Employee

  • The Return to Work Interview must be conducted after every absence. It should be private and confidential, informal, structured and factual,
    carried out in a positive and supportive way, recorded and taken seriously.

For completion by the line manager

  • Job Title

  • Department

  • First day of Absence

  • Date returned to work

  • Total days absent from work

  • Reason given for absence

  • Date and time of notification

  • Method of notification

  • Expected date of return

  • Is absence due to an injury at work

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

Return to Work Interview

  • For completion by the line manager (as appropriate)

RTW Discussion Record Notes

  • "Welcome back" : Tell them why they've been missed. Explain that the RTW is not part of a disciplinary process.

  • How are you now?

  • Are you able to carry out your normal hours and duties?

  • What was the cause of your absence?

  • Was the absence related to an accident/incident at work?

  • Was an accident/incident report form filled-out?

  • Why not?

  • Did you consult a doctor or other practitioner?

  • Are you on medication which may affect your performance?

  • What effects could this have?

  • Are there any issues that you would like to raise following the recent absence?

Summary and Sign-Off

  • Summary of action points agreed to be taken

  • Review Date for Agreed Action

  • Employee

  • Date Signed

  • Manager

  • Date Signed

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.