Return to Work form example

Managing Sickness Absence - Return to Work Form (Example)

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) bear in mind the duty to make reasonable adjustments under the Disability Discrimination Regulations.

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: