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Return to work form – Steve

This form is to be used on return to work following any period of incapacity. If this period extends beyond 7 days (including weekends, etc.) you must also provide a medical statement from your Doctor (Fit note)


    Name:

    Site/s:

    Date:

    What were the first and last dates on which you were incapable of working, regardless of whether these were working days?

    From:

    To:

    Number of days off work:

    Fit note / proof of sickness provided?

    Please attach Fit note / Proof of sickness

    What was the nature of your incapacity, i.e. the name of your illness or the symptoms of your incapacity?

    What steps did you take to alleviate your incapacity, e.g. any medication taken, visit to your Doctor, etc?

    Are you fully recovered from the incapacity / illness?

    If not, when do you expect to make a full recovery?

    If No:

    Is a recurrence likely or are you receiving ongoing medication / treatment / physio that will lead to further absence?

    If Yes:

    Would you like to discuss any changes that might help in your return to work?

    If yes:

    Declaration:

    I confirm that to the best of my knowledge and belief, the above information is correct and that I was absent from work for the reason stated. I understand that my employer may take steps to verify this information and that giving false information is a disciplinary offence.

    Employee’s signature:

    Date:

    Company signature:

    Date: