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Return to Work Interview Form
A return to work form is designed to ascertain if the employee is fit to return to work and also captures any adjustments that may need to be made.
Your Name:
Please enter your email address so a copy of the form can be sent:
Start
Employee Name
Date of absence
Employee confirms they are fit for work.
Yes
No
Employee updated on work issues (including issues caused by absence)?
Yes
No
Is the absence related to a work related accident?(if yes, has the appropriate documentation been completed?)
Yes
No
Is a phased return appropriate?
Yes
No
Details of phased return if applicable:
Is there an underlying reason for the absence?
Yes
No
Reason if applicable:
Has there been a change in the employees’ circumstances?
Yes
No
Summary of change if applicable:
Did you consult a doctor?
Yes
No
Have you suffered from the illness before?
Yes
No
Number of working days lost due to absence in the last 12 months
Is there concern about the level of sickness absence?
Yes
No
Has the employee been informed about the importance of regular attendance and the fact that poor attendance can lead to informal and formal monitoring?
Yes
No
Has the employee reached the absence triggers (5 days or more or 3 occasions in a 6 month period)?
Yes
No
Has your doctor confirmed your fit to return to work? (for absences more than 7 days)
Yes
No
N/A
Are you suffering from any symptoms or after effects?
Yes
No
Notes of any further discussions:
Employee Comments:
Signed Manager:
Signed Employee
Date of Interview
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