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Back to Work Form Template

This form template for returning to work can be used by an employee after a long absence (for example, due to injury or illness) to list the days of absence and their cause. It also helps to collect important information on how the employee can be reintegrated into the world of work quickly and safely.

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Back to Work Form Template

Details of Resumption of Work

This form must be completed after each absence, except for holidays, to cover all periods of sick leave from the first to the seventh calendar day inclusive.

Employee data

Job description
Employee number
Department
Contact Number
Name of Line Manager
Date of meeting

Day/s of Absence (to be completed by your line manager with you)

First Date of Absence
Letzter Tag der Abwesenheit
Date returned to Work
Total number of Working Days Absent
Enter percentage of total absence
Supporting information (if applicable), e.g. doctor's letter
Add media

Contacting the company

Did you properly notify the employer of your absence?
Who did you speak to?
When did you contact the company?

Previous sickness absence (to be completed by your line manager if applicable)

Previous Absences - List each separate occasion, with number of days and reason.
Total number of days absent in the last 6 months:
Total number of days absent in the last 12 months :
Number of periods in current year
Are you aware of the absence reporting procedures?

Details of the absence

Has the employee consulted a doctor during her absence?
Referral from the occupational medicine department?
Will this absence trigger an absence hearing?
Will this absence period be paid?
Support / action ( if applicable )
Details of the discussion when returning to work (welcome)
Employee feedback

Sign-Off

Action Plan (Agreed adjustments, Review dates and Comments)
Employee signature
Managers signature
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