Return to Work Form This form should be used to record a return to work discussion after a period of absence where a review point has been met or where there is any other cause for concern. Please see the Guidance Carrying Out a – Return to Work Discussion for further information. Attach notes on a separate sheet of paper if required. Section 1 Information – Employee Name Staff Number Managers Name Absence Reason Absence Start Date End Date Days Lost Section 2 Absence Review – Welcome employee back to work Discuss and agree accuracy of absence record (including 12 month history) Check employee is fit for full duties Discuss any underlying medical condition (if applicable, note supports below) Discuss any work-related factors Update on any workplace developments contributing to absence Section 3 Note of Agreed Support/Adjustments – Note any underlying factors affecting attendance at work and any agreed support mechanisms or adjustments required, including timescales for review. (See Guidance Note Workplace Adjustments & – Support). OH referral required (complete separately using OH referral form) Section 4 Review Points & Stages – Confirm employee understanding of Tick if any Review Points have been reached as a Review Points (see below) result of this absence then record the appropriate outcome below 3 occasions of absence within the last 3 months 5 occasions of absence within the last 12 months 12 or more days’ sickness absence, accrued over more than 1 period of absence, within the last 12 months (Pro-rated for part-time staff) Any recurring, recognisable pattern (e.g. frequent absenteeism on a Monday) Outcome Informal Attendance Improvement Plan No Further Action (AIP) (***Complete form overleaf) (Note the reason for no further action below) Initiate Formal Stage 1 Hearing Notes (See guidance) Initiate Formal Stage 2 Hearing (See guidance) Initiate Formal Capability Hearing (See guidance) Employee Signature Date Managers Signature Date Managers/Administrators Return to Work recorded on Core? Absence Stage recorded on Core? only Yes N/A Informal Attendance Improvement Plan (AIP)
Return to Work Form This form should be used to record a return to work discussion after a period of absence where a review point has been met or where there is any other cause for concern. Please see the Guidance – Carrying Out a Return to Work Discussion for further information. Attach notes on a separate sheet of paper if required. Section 1 – Information Employee Name Staff Number Managers Name Absence Reason Absence Start Date End Date Days Lost Section 2 – Absence Review Welcome employee back to work Discuss and agree accuracy of absence record (including 12 month history) Check employee is fit for full duties Discuss any underlying medical condition (if applicable, note supports below) Discuss any work-related factors contributing to absence Update on any workplace developments Section 3 – Note of Agreed Support/Adjustments Note any underlying factors affecting attendance at work and any agreed support mechanisms or adjustments required, including timescales for review. (See Guidance Note – Workplace Adjustments & Support). OH referral required (complete separately using OH referral form) Section 4 – Review Points & Stages Confirm employee understanding of Review Points (see below) Tick if any Review Points have been reached as a result of this absence then record the appropriate outcome below 3 occasions of absence within the last 3 months 5 occasions of absence within the last 12 months 12 or more days’ sickness absence, accrued over more than 1 period of absence, within the last 12 months (Pro-rated for part-time staff) Any recurring, recognisable pattern (e.g. frequent absenteeism on a Monday) Outcome Informal Attendance Improvement Plan (AIP) (***Complete form overleaf) No Further Action (Note the reason for no further action below) Initiate Formal Stage 1 Hearing (See guidance) Notes Initiate Formal Stage 2 Hearing (See guidance) Initiate Formal Capability Hearing (See guidance) Employee Signature Date Managers Signature Date Managers/Administrators only Return to Work recorded on Core? Absence Stage recorded on Core? Yes N/A Informal Attendance Improvement Plan (AIP)