RETURN TO WORK DISCUSSION FORM To be completed in the following circumstances; When requested by either party for absences of less than 8 calendar days. Mandatory for absences of 8 calendar days or more. Mandatory when an employee has reached a short term absence trigger and an Informal Absence Counselling Meeting is required (please refer to guidance on page 3 of this form). The form is to be completed by the employee’s line manager and signed by both parties. The form is to be retained by the line manager and a copy provided to the employee. Where there is a stated in any of the blue section then a copy must also be sent to Human Resources. ‘yes’ First Name: Surname: Job Title: Staff Number: School/Institute/Service: Period of sickness absence From: To: Date returned to work: number of working days absent: Reason for sickness absence (link to ): Was the sickness absence due to a work related accident? YES/NO If YES, who did the employee report it to? Was the absence notification procedure followed? YES/NO If NO, please provide the employee with a reminder of the procedure Is the employee fit enough to return to work? YES/NO Is the employee currently undergoing any treatment or taking any YES/NO medication which may affect their ability to carry out their job? Are there any ongoing or temporary adjustments required to enable the YES/NO Employee to carry out their job role? If yes, please provide further details in Action to be taken by Line Manager section. Has the Employee been referred to Occupational Health? YES/NO If NO consider if a referral would be appropriate. If unsure please speak to your HR Representative for further advice. Does the Employee consider themself to be disabled (as defined the YES/NO Equality Act 2010)?
RETURN TO WORK DISCUSSION FORM To be completed in the following circumstances; When requested by either party for absences of less than 8 calendar days. Mandatory for absences of 8 calendar days or more. Mandatory when an employee has reached a short term absence trigger and an Informal Absence Counselling Meeting is required (please refer to guidance on page 3 of this form). The form is to be completed by the employee’s line manager and signed by both parties. The form is to be retained by the line manager and a copy provided to the employee. Where there is a ‘yes’ stated in any of the blue section then a copy must also be sent to Human Resources. First Name: Surname: Job Title: Staff Number: School/Institute/Service: Period of sickness absence From: To: Date returned to work: number of working days absent: Reason for sickness absence (link to ): Was the sickness absence due to a work related accident? If YES, who did the employee report it to? YES/NO Was the absence notification procedure followed? If NO, please provide the employee with a reminder of the procedure YES/NO Is the employee fit enough to return to work? YES/NO Is the employee currently undergoing any treatment or taking any medication which may affect their ability to carry out their job? YES/NO Are there any ongoing or temporary adjustments required to enable the Employee to carry out their job role? If yes, please provide further details in Action to be taken by Line Manager section. YES/NO Has the Employee been referred to Occupational Health? If NO consider if a referral would be appropriate. If unsure please speak to your HR Representative for further advice. YES/NO Does the Employee consider themself to be disabled (as defined the Equality Act 2010)? YES/NO
return-to-work-discussion-form-aug-2016_vh.docx