Return to Work form
Managing Sickness Absence- Return to Work Form
This form must be completed and signed by all members of staff following each
episode of sickness absence and countersigned by their immediate line manager. The
form will be held on the individual’s Personal File. For absences exceeding 3 calendar
days, a medical certificate must also be provided by the member of staff.
Surname .................................... Other names: ..............................................
Post Title ................................................... Department....................................
Absence reported to ................................. at ............(time) on .................. (date)
Reason for absence
......................................................................................................................
......................................................................................................................
First day of illness ................................. Last day of illness ...............................
First day of absence .............................. Date of return to work ..........................
Total number of days/shifts of absence on this episode ......................
Has a medical certificate been provided: YES / NO / Not required
Was your absence a result of an injury at work or work related accident or illness:
YES /NO
If yes, please give details
When was the incident report .......... (time) ............. (date)
To whom was it reported:
Was your absence a result of an accident where damages may be claimed from a third party (e.g. road traffic accident?) YES / NO
If yes, please give details
SUMMARY OF SICKNESS ABSENCE IN PREVIOUS 12 MONTHS
Number of days ................. Number of episodes ................
SUMMARY OF RETURN TO WORK INTERVIEW
ACTION REQUIRED
(e.g.Referral to Occupational Health; Referral to Staff Counselling Service)
Alterations to working arrangements agreed (hours/environment etc)
Formal meeting arranged in accordance with Managing Sickness Absence Policy
Manager’s signature ................................. Date ..........................................
I certify that I have been unable to work during the period above due to sickness as
stated and confirm the content of discussions as above.
Employee’s signature:
Date: