Return To Work Interview

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– Step 1 of 3

Interview Details

Employee Name *

Line Manager *

Manager's Email (for confirmation) *

Date of Interview *

About the Absence

Number of absences in the past six months: *

Number of occasions of absence in the last six months:

What was the reason for this absence? *

How long was the employee absent from work?

Days *

From *

Dates of absence

To *

Dates of absence

Did the employee comply with the notification procedure? *

Please state reasons: *

Was this absence related to a previous absence(s)? *

Please give date / nature of previous absences(s) *

Is there a likelihood of reoccurrence? *

How does the employee think it will that affect their work? *

Is the employee fit for work? *

Why does the employee think they are not fit for work? *

Did the employee seek advice from their Doctor/ Consultant? *

Date of visit(s): *

Was the employee prepared to inform you of the advice given? *

What was the advice given? *

Does the employee require further medical treatment? *

Ask the employee to give full details *

Detail any advice given to the employee by their Doctor/Consultant

Detail any medication that the employee is taking which may have an effect on the operation of any machinery or work equipment.

Detail any underlying problems relating to the absence (personal, work or domestic) and can any assistance be given to the employee by the company?

Detail any further action or adjustments which may be required and if appropriate, time- scales agreed. (Does the employee have a risk assessment which needs to be reviewed?)

Additional Notes:

Employee Statement

I can confirm that the information I have provided above is correct, and that I am fit to return to work performing my usual duties.

Employee

Name *

Job Title *

Signed *

Clear Signature

Date *

for have have

Company Representative

Name *

Job Title *

Signed *

Clear Signature

Date / Time *