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Employee Return To Work Form
"I need an Employee Return To Work Form for a staff member returning from extended sick leave in March 2025, including provisions for a phased return over 4 weeks and specific workplace adjustments for a back injury."
1. Employee Information: Basic details including name, employee ID, department, contact information
2. Absence Details: Information about the period of absence including start date, end date, and reason for absence
3. Return Date: Confirmed date of return to work and any specific arrangements
4. Health Status Declaration: Employee's declaration of current health status and fitness to return to work
5. Manager Review: Section for manager's assessment, comments and approval of return to work
1. Phased Return Plan: Details of graduated return schedule including reduced hours or modified duties, to be included when recommended by healthcare provider
2. Workplace Adjustments: Specific modifications required to workspace or duties to accommodate medical conditions or disabilities
3. Follow-up Schedule: Schedule of planned review meetings and check-ins, particularly relevant for longer-term health conditions
1. Medical Certificate: Copies of fit notes or medical certificates supporting the absence and return to work
2. Risk Assessment: Updated workplace risk assessment documentation if required due to health condition
3. Occupational Health Report: Any relevant occupational health recommendations or reports supporting the return to work
Authors
Return Date
Phased Return
Working Hours
Workplace Adjustments
Fit Note
Medical Certificate
Occupational Health Assessment
Risk Assessment
Company
Employee
Line Manager
HR Representative
Normal Working Pattern
Modified Duties
Review Period
Support Measures
Reasonable Adjustments
Return to Work Plan
Health and Safety Requirements
Absence Details
Health Declaration
Risk Assessment
Workplace Adjustments
Working Hours
Return Arrangements
Support Requirements
Health and Safety
Medical Certification
Review Process
Data Protection
Occupational Health
Manager Assessment
Employee Declaration
Signatures and Approvals
Follow-up Arrangements
Monitoring Period
Performance Expectations
Confidentiality
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