Return To Work Interview Form printable pdf download

Return To Work Interview Form

RETURN-TO-WORK

INTERVIEW FORM

A return to work interview is usually held if a member of staff has had 3 separate episodes of sickness absence within a

6 month period. The interview should take place as soon as possible upon their return to work from the last period of

absence. This form should be completed and signed by both the member of staff and line manager and returned to the

Human Resources Department. A copy will be held on the member of staff’s personal file.

Further guidance on undertaking return to work meetings can be obtained from the Human Resources Department.

Employee Details

Name: ……………………………………………… Job Title: …………………………………………………….

Department: ………………………………………………………………………………….………………………..

Absence Details

Sickness absence over the past 6 months:

Reason for Absence (please see list overleaf)

From

Interview

Date: ………………..…..…

Line Manager conducting interview: ………...….……………….……..……………

Was medical advice sought for the most recent period of absence and for the previous absences detailed

above?

Are any follow up medical appointment needed?

Is a self certificate or medical certificate required?

Was medication prescribed for the above periods of absence?

Is any medication being taken at present?

If yes, could this medication affect the ability to operate machinery or cause drowsiness?

Has the member of staff fully recovered?

Return To Work Interview Form