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
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.