Return to Work Interview Form
Please complete this form as part of the return-to-work process following your absence.
Employee Full Name
*
First Name
Last Name
Employee Position/Department
*
Date of Return to Work Interview
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dates of Absence (Start and End)
*
Reason for Absence
*
Please Select
Illness
Injury
Personal Leave
Family Emergency
Bereavement
Other
Has the employee provided any required documentation for their absence?
*
Yes
No
Is the employee fit to return to work?
*
Yes, fully fit
Yes, with adjustments
No, further absence required
Are any workplace adjustments required for the employee's return?
*
Modified duties
Reduced hours
Ergonomic equipment
Phased return
No adjustments required
Other
Briefly describe any concerns, ongoing symptoms, or support needed by the employee
Summary of discussion and actions agreed upon
*
Interviewer's Name
*
Interviewer's Position
*
Employee Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: