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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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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
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
Action Plan (Agreed adjustments, Review dates and Comments)
Employee signature
Managers signature
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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