Return to Work Discussion Form
Employee Information
Name
First Name
Last Name
School/Institute/Service
Personal ID#
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Title
Period of sickness
From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Return to Work
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Total number of working days absent
Reason for sickness absence
Rows
Yes
No
Any thoughts?
Has there been an absence of illness due to a work-related accident? If YES, to whom did the employee report?
1
2
Has the absenteeism notification procedure been followed? If NO, please provide employee reminder of the procedure.
3
4
Is the employee fit enough to return to work?
5
6
Is the worker currently receiving any treatment or taking any medication that may affect his or her ability to carry out his / her job?
7
8
Are there any ongoing or temporary arrangements necessary for the employee to fulfill the job role? If yes, please provide more detailed information about the action to be taken by the Department Manager.
9
10
Has the employee been referred to Occupational Health? NO If you consider whether a recommendation is appropriate. If you are unsure, please speak to your HR Representative for further suggestions.
11
12
Does the employee consider themselves disabled (defined under the Equality Act 2010)?
13
14
Is the sickness absence due to their disability?
15
16
If yes, is a Disability Management Meeting necessary? Please speak to your HR Representative for further advice.
17
18
After reviewing and discussing the disease history of employees for the last 6 months, has the employee hit a trigger point under section 6 of the Effective Management of Sickness Absence Procedure?
19
20
Does the employee need a phased return to work for up to 4 weeks? If yes, specify how many weeks have been accepted
21
22
Further Details;
Actions to be taken by Employee:
Actions to be taken by Line Manager:
Line Manager Name
First Name
Last Name
Line Manager's Signature
Employee's Signature
Submit
Should be Empty: