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Return To Work Restrictions Form
"I need a Return To Work Restrictions Form for an employee returning from long-term sick leave in February 2025, with specific provisions for reduced hours and ergonomic workspace requirements for an office-based role."
1. Employee Information: Basic details including name, employee ID, department, and role
2. Absence Details: Information about the reason for absence and duration
3. Medical Clearance: Confirmation of fitness to return to work
4. Work Restrictions: Specific limitations or modifications required
5. Duration of Restrictions: Timeline for temporary restrictions or adjustments
6. Signatures: Employee and manager acknowledgment
1. Phased Return Schedule: Detailed timeline for gradual return to full duties - use when employee requires graduated return to work
2. Workplace Adjustments: Specific modifications to workplace or equipment - use when physical workplace changes are needed
3. Review Schedule: Planned check-in dates to assess progress - use for long-term or complex returns
1. Medical Certificate: Copy of fit note or medical clearance
2. Risk Assessment: Detailed workplace assessment for return
3. Occupational Health Report: Professional recommendations if applicable
Authors
Adjustments
Company
Effective Date
Employee
Fit Note
Full Duties
Health and Safety Requirements
Line Manager
Medical Professional
Modified Duties
Normal Working Hours
Occupational Health Provider
Phased Return
Reasonable Adjustments
Restricted Duties
Return to Work Date
Review Period
Risk Assessment
Temporary Modifications
Workplace
Workplace Restrictions
Working Pattern
Medical Information
Workplace Restrictions
Duration and Review
Health and Safety
Workplace Adjustments
Working Hours
Duties and Responsibilities
Supervision Requirements
Performance Monitoring
Risk Assessment
Medical Review
Compliance Requirements
Confidentiality
Data Protection
Review and Modification
Emergency Procedures
Reporting Requirements
Training Requirements
Acknowledgment and Agreement
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