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
Full TimePart TimeSemester/ Term Time
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
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
SUN MON TUES WED THURS FRI SAT
Actual hours worked
Please pay remaining hrs as: SP/AL
Week 2
SUN MON TUES WED THURS FRI SAT
Actual hours worked
Please pay remaining hrs as: SP/AL
Week 3
SUN MON TUES WED THURS FRI SAT
Actual hours worked
Please pay remaining hrs as: SP/AL
Week 4
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
SicknessAccident
Accident was
At workOutside Work
Reason for sickness :
CH Chest, Heart, Respiratory problemsCO Cold, Flu, Virus, InfectionsGI Gastro-Intestinal problemsHM Headache, MigraineOP Operations, Hospital AdmissionsMK Musculoskeletal problems (Back, Neck, Wrist, Knee, etc)ST Stress, Anxiety, Depression, etc.OT Other
Manager Signature
Clear
Employee Signature
Clear
Should be Empty:

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

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

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

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

Phased Return To Work Form

Employee Information

RETURN TO WORK PATTERN