Return to Work Meeting following
Unplanned Absence (including Sickness)
SUBMIT
Complete the following section prior to the meeting
Name of employee/sub-contractor:
Job title:
Name of employee/sub-contractor's manager:
Length of employee/sub-contractor's absence:
First date of employee/sub-contractor's absence:
Date of employee/contractor's return to work:
Is the absence part of an overall pattern?
(if yes, discuss with HR prior to RTW interview so that this can be discussed with the employee/sub-contractor)
To be completed by the manager with the employee/sub-contractor during the meeting
Date of return-to-work interview:
What was the reason for this most recent absence?
Was the correct reporting of absence procedure followed?
Yes
No
If not, what is the employee/sub-contractor's explanation for this?
Absence due to illness or injury
If this absence was due to illness, did the employee/sub-contractor consult a doctor?
Yes
No
Were any medical certificates or advice obtained? (attach if relevant)
Yes
No
Is the employee/sub-contractor taking any medication that could have any side effects which could affect their work, day to day activities or be a safety hazard?
Yes
No
If yes, give details of medication:
Are any adjustments required to accommodate medication usage (ensure that the employee/sub-contractor is safe to drive to work or as part of their role if this is required)?
Does the employee/sub-contractor have any type of ongoing or underlying health issue or disability?
Yes
No
If yes, please give details:
Does the employee/sub-contractor feel that factors at work may have caused or contributed to their absence?
Yes
No
If yes, please provide details:
Where the employee/sub-contractor feels that work factors may have contributed to their absence, please detail what has been agreed in order to support the employee:
Discuss any overall absence patterns if this is an area of concern and summarise the plan to address this:
Has the employee/sub-contractor confirmed that they are fit and ready to return to work?
Yes
No
Discuss whether they are fully able to undertake all aspects of their normal role, or whether they require any temporary adjustments:
Does the manager/interviewer believe the employee/sub-contractor is fit to return to work?
Yes
No
Any further comments from the manager/interviewer:
Sickness
Other
Number of
occasions
of unplanned absence in last 12 months*:
Total number of
days
of unplanned absence in last 12 months*:
Signature (manager):
Signature (employee / sub-contractor):
Date form completed:
*The 12 months preceding the final day of this absence