Return to work from ILLNESS

 

ABSENCE & ILLNESS RETURN TO WORK FORM

 

TO BE COMPLETD BY MANAGER/DIRECTOR WITH EMPLOYEE IMMEDIATELY FOLLOWING EMPLOYEES RETURN TO WORK
Date of Interview				Interview conducted by
First day absent			Last day absent		Date & Time
No of working days absent			No of days absent in last 12 months		Absence notified by:
Further details about nature of illness/injury/absence.
Do you feel you are fit to return to work?				If you are returning prior to the expiry of a current certificate, do you have the Doctor’s agreement?
Did you consult your GP (or hospital doctor) or other suitably qualified health practitioner (e.g. nurse at GP surgery, hospital, pharmacist) during this absence?
If No, why not?  If yes, who did you consult and what advice did they give?
Are you taking any medication?				Is there is anything regarding your medication we should be aware of?
Have you been advised to avoid driving/using machinery? If yes, give details.
Do you have any recurring or underlying problems with your health? If yes, please explain.
How would you describe your general state of health?
Is the cause of your absence likely to recur?       Are you experiencing any family or personal problems? (detail                                                                        If applicable)
Is there any aspect of your job which you feel is contributing to your health problems (or which potentially could do?) Do you have suggestions of anything we could do to help you to overcome this?
List agreed action points and timescales:
Optional questions - only discuss where relevant
You have a poor attendance record, characterised by short periods of self certified absence for minor unrelated illness or injury.  How do you explain this?
What action are you going to take to reduce your level of sickness?
Would you have any objection if we wanted to contact your doctor for a medial report?
I confirm this is an accurate record of the discussion with the Manager and declare myself fit for work.   Employee’s signature                                                  Date
I confirm that I have discussed my above recommendation with the employee.   Signed (Manager)                                                       Date