Phased Return To Work Form

Phased Return To Work Form
NOTES FOR COMPLETING THIS FORM: Please use this form to detail the gradual return of a staff member during absenteeism. Please elaborate on the full refund period. NOTE: If the gradual return lasts more than four weeks after the agreement with HR, a new form must be completed. All boxes below should be completed within hours.
Employee Information
Name
First NameLast Name
Hours of work
Department
Job Title
First date unfit for work
MonthDayYear
Date
Date returned to work
MonthDayYear
Date
Last date unfit for work
MonthDayYear
Date
Employee's Normal Working Pattern
Rows SUN MON TUES WED THURS FRI SAT
number of working hours
RETURN TO WORK PATTERN
Once the temporary fixes have been agreed with HR, complete the following section to set the time the employee will work each day for each week.
Week 1
Rows SUN MON TUES WED THURS FRI SAT
Actual hours worked
Please pay remaining hrs as: SP/AL
Week 2
Rows SUN MON TUES WED THURS FRI SAT
Actual hours worked
Please pay remaining hrs as: SP/AL
Week 3
Rows SUN MON TUES WED THURS FRI SAT
Actual hours worked
Please pay remaining hrs as: SP/AL
Week 4
Rows SUN MON TUES WED THURS FRI SAT
Actual hours worked
Please pay remaining hrs as: SP/AL
Anything you want to add:
Reason for phased return to work
Accident was
Reason for sickness :
Manager Signature
Clear
Employee Signature
Clear
Should be Empty:

Rows	SUN	MON	TUES	WED	THURS	FRI	SAT
Actual hours worked
Please pay remaining hrs as: SP/AL

RETURN TO WORK PATTERN