BACK TO WORK INTERVIEW FORM

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Employee Information. Section 1.

Full Name

Job Title

Department/Location

Number of days absent from work

First date of my absence

Date of my return to work

Total number of absences

Has your sickness ended?

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Field label

Any supporting medical certification/documentation:

Please email any relevant and supporting infomation or documents to office@old-george.co.uk

Alternatively they can be scanned by a manager.

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Return to work meeting form. Section 2.

Date of return to work meeting

Attendees

Medical certification provided:

1. Reason for absence

2. Health Status

3. Work-related issues

4. Support and accommodations:

5. Return to work plan:

6. Date for follow up review:

7. Any other comments

Employee Confirmation:

By checking this box, I confirm that all the details listed above are correct.

Employee Name:

Manager Confirmation:

By checking this box, I confirm that all the details listed above are correct.

Manager Name: