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Back To Work Form

Back To Work Form Template for New Zealand

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Key Requirements PROMPT example:

Back To Work Form

"I need a Back to Work Form for a manufacturing company employee returning from a workplace injury in March 2025, including provisions for a graduated return plan and specific machinery operation restrictions."

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Document background
The Back to Work Form is a critical document used in New Zealand workplaces to manage and document an employee's return to work following an absence. It is designed to comply with New Zealand's workplace legislation, including the Health and Safety at Work Act 2015, Privacy Act 2020, and Employment Relations Act 2000. The form is typically used when employees return from extended sick leave, injury-related absence, parental leave, or other significant periods away from work. It captures crucial information about the employee's fitness to return, any medical clearances required, necessary workplace modifications, and graduated return plans if applicable. The document helps ensure a safe and well-managed return to work process while protecting both employer and employee interests and meeting legal obligations.
Suggested Sections

1. Employee Information: Basic details including name, position, department, and employee ID

2. Absence Details: Information about the period of absence, including start and end dates, and reason for absence (with appropriate privacy considerations)

3. Return to Work Details: Proposed return date, whether return is full or graduated, initial working hours/days

4. Health Status Declaration: Employee's confirmation of fitness to return to work, including any ongoing medical conditions that may affect work

5. Required Workplace Adjustments: Any modifications, equipment, or support needed to facilitate safe return to work

6. Sign-off Section: Signatures from employee, manager, and date of completion

Optional Sections

1. Medical Clearance Details: Section for medical practitioner's clearance details - required when returning from serious illness/injury or extended medical leave

2. Graduated Return Plan: Detailed schedule of graduated return to work - used when employee requires phased return

3. ACC Details: Information related to ACC claim and case manager - included for work-related injury cases

4. Risk Assessment: Workplace hazard and risk assessment - required for cases where specific safety concerns need addressing

5. Additional Support Requirements: Details of extra support, training, or supervision needed - used when significant workplace adjustments are required

Suggested Schedules

1. Medical Certificate: Attached medical certificate from healthcare provider confirming fitness to return

2. Graduated Return Schedule: Detailed weekly schedule showing progressive increase in hours/duties

3. Workplace Modification Checklist: List of required workplace modifications and their implementation status

4. Health and Safety Checklist: Standard checklist ensuring all safety requirements are met for return to work

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Linkedin in social icon imageX social icon image
alex.den.21@genieai.co
Relevant Industries

Healthcare

Manufacturing

Construction

Professional Services

Retail

Education

Government

Technology

Transportation

Hospitality

Mining

Agriculture

Financial Services

Telecommunications

Relevant Teams

Human Resources

Health and Safety

Operations

People and Culture

Risk Management

Employee Relations

Occupational Health

Legal

Management

Relevant Roles

HR Manager

Health and Safety Manager

Operations Manager

Department Manager

Line Supervisor

HR Administrator

Occupational Health Nurse

Return to Work Coordinator

People and Culture Manager

Workplace Health and Safety Officer

Employee Relations Manager

HR Business Partner

Risk Management Officer

Industries
Health and Safety at Work Act 2015: Ensures workplace safety and sets obligations for both employers and employees in maintaining a safe work environment, including requirements for return-to-work assessments and accommodations
Privacy Act 2020: Governs the collection, storage, and handling of personal information, including medical details that might be included in a back-to-work form
Human Rights Act 1993: Protects against discrimination based on disability, illness, or injury, ensuring fair treatment in return-to-work processes
Employment Relations Act 2000: Sets out fundamental employment rights and obligations, including requirements for good faith dealing between employers and employees during return-to-work processes
Accident Compensation Act 2001: Relevant for employees returning after work-related injuries, outlining requirements for rehabilitation and return-to-work programs
Holidays Act 2003: Relevant for managing sick leave entitlements and return-to-work arrangements following extended leave
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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