PART TWO To be completed by employee in the presence of immediate supervisor/line manager on return to work. State briefly why you were unfit for work: Are you fit enough for all duties? YES YES / / NO NO Do you have a further YES YES / / NO NO Doctor’s appointment? Is there any support we can provide? If yes, please detail. YES / NO YES / NO Do you need a referral to Occupational Health or other? YES / NO If yes, referral to be arranged by manager. I certify that I was absent from duty from to ………………………… ………………………… (number of working days of illness/accident/work accident. …………) because I declare that I have not worked during the period of sickness which is detailed above. I confirm that the information given on this form is correct and understand the issues and actions described above. Employee Name Employee Signature Date Manager Name Manager Signature YES / NO Date A copy of this form can be given to the employee.
PART TWO To be completed by employee in the presence of immediate supervisor/line manager on return to work. State briefly why you were unfit for work: Are you fit enough for all duties? YES / NO YES / NO Do you have a further Doctor’s appointment? YES / NO YES / NO Is there any support we can provide? If yes, please detail. YES / NO YES / NO Do you need a referral to Occupational Health or other? If yes, referral to be arranged by manager. YES / NO I certify that I was absent from duty from ………………………… to ………………………… (number of working days …………) because of illness/accident/work accident. I declare that I have not worked during the period of sickness which is detailed above. I confirm that the information given on this form is correct and understand the issues and actions described above. Employee Name Employee Signature Date Manager Name Manager Signature YES / NO Date A copy of this form can be given to the employee.