Return to Work Interview Form
Employee Name
Job Title
Department
Date of Return to work Interview
First Day of Absence:
Last Day of Absence:
Total number of calendar days off work:
Manager to check ESR to clarify the dates and to make sure the last day of absence is the last day they were unable to work and NOT the day before the next shift starts
Reason for absence:
Please give a brief description of the reason for the absence
Has the employee seen a doctor?
Yes
No
Please record any advice given by the doctor related to the employees health and wellbeing at work
Is the absence due to a work related injury?
Yes
No
Manager to check that appropriate paperwork is completed if the absence is due to a work related injury
Does the employee feel safe at home?
Yes
No
Please record response and advice provided. Please consider if there are any indicators of domestic abuse.
Action Taken:
No Action
Refer to the Reasonable Adjustment Guidance
Refer to Attendance Support Meeting
Invite letter to Attendance Support Review Meeting given
Refer to OH&WbS
Refer to the Sickness Absence Support Policy
Refer to Domestic Abuse guidance
Other (please state
I have read, understood and agreed the above is an accurate account of the discussion.
Employee
Manager
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