Return to Work Following Sickness – SAM

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Employee Update of Details Form

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Return to Work Form

A return to work form is designed to ascertain if the employee is fit to return to work and also captures any adjustments that may need to be made.

Your Name:

Site Name:

Please enter your email address so a copy of the form can be sent:

Please enter the employees' email address so a copy of the form can be sent to them:

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Employee Name
Date of absence
Number of working days absent
Employee confirms they are fit for work. YesNo
Employee updated on work issues (including issues caused by absence)? YesNo
Is the absence related to a work related accident?(if yes, has the appropriate documentation been completed?) N/AYesNo
Is a phased return appropriate? YesNo
Details of phased return if applicable:
Is there an underlying reason for the absence? YesNo
Reason if applicable:
Has there been a change in the employees’ circumstances? YesNo
Summary of change if applicable:
Did you consult a doctor? YesNo
Have you suffered from the illness before? YesNo
Number of working days lost due to absence in the last 12 months
Is there concern about the level of sickness absence? YesNo
Has the employee been informed about the importance of regular attendance and the fact that poor attendance can lead to informal and formal monitoring? YesNo
Has the employee reached the absence triggers (5 days or more or 3 occasions in a 6 month period)? YesNo
Has your doctor confirmed your fit to return to work? (for absences more than 7 days) YesNoN/A
Are you suffering from any symptoms or after effects? YesNo
Notes of any further discussions:
Employee Comments:
Date of Interview

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