Return to Work Interview Template

• Employee name

• Conducted on

  Date

• Document No.

• 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

• Date returned to work

  Date

• Total days absent from work

• Reason given for absence

• Date and time of notification

  Date

• Method of notification

  Phone call

  Email

• Expected date of return

  Date

• Is absence due to an injury at work

  Yes

  No

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

  Yes

  No

• 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?

  Yes

  No

  N/A

• Why not?

• Did you consult a doctor or other practitioner?

  Yes

  No

  N/A

• Are you on medication which may affect your performance?

  Yes

  No

  N/A

• 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

  Date

• Employee

  Sign

• Date Signed

  Date

• Manager

  Sign

• Date Signed

  Date