Information
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Employee name
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Conducted on
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Document No.
About the Employee
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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
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Job Title
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Department
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First day of Absence
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Date returned to work
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Reason given for absence
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Date and time of notification
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Method of notification
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Expected date of return
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Is absence due to an injury at work
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If accident at work, has an accident report been completed
Return to Work Interview
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For completion by the line manager (as appropriate)
RTW Discussion Record Notes
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"Welcome back" : Tell them why they've been missed. Explain that the RTW is not part of a disciplinary process.
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How are you now?
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Are you able to carry out your normal hours and duties?
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What was the cause of your absence?
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Was the absence related to an accident/incident at work?
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Was an accident/incident report form filled-out?
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Why not?
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Did you consult a doctor or other practitioner?
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Are you on medication which may affect your performance?
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What effects could this have?
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Are there any issues that you would like to raise following the recent absence?
Summary and Sign-Off
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Summary of action points agreed to be taken
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Review Date for Agreed Action
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Employee
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Date Signed
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Manager
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Date Signed