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1.Name Of Employee |
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Job Title: |
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Date of Return to
Work Discussion |
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Dates of this
Absence |
From: |
To: |
Total
number of working days on this occasion: |
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Cumulative total to
date (12 month rolling cycle) |
Number
of cumulative days: |
Number
of cumulative occasions: |
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Trigger Points |
4
spells in 12 months Y
/ N |
2
consecutive weeks Y
/ N |
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2. Reason For this Absence |
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3. Was
the absence related to work i.e. accident or illness |
Yes |
No |
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If
Yes was it reported? |
Yes |
Date:
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No |
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4. Is the
employee fit to return to work?
Yes / No |
4a. Is the absence
related to a disability? Yes / No |
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5. Are
there any adjustments to workplace/ hours / duties to be made that could
facilitate return to work or eliminate absence? |
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6. Details of Support
offered |
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7. Details of follow up action |
Details |
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No
follow up |
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For
further informal review |
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Targets
Agreed |
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Refer
to HR for formal review |
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Refer
to Occupational Health |
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8. Line Manager’s Name |
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Signature
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Employee
Name |
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Signature |
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Date |
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