Return To Work Interview – Essential Homecare Services NI

Name of Employee: *

Job Title: *

Date of Recent Absence: *

Return to work date: *

Date of return to work interview: *

Conducted by: *

Reason For Absence: *

Is the absence work related? *

(check if an incident form has been completed)

Is the absence pregnancy related? *

(if yes then a risk assessment must be undertaken)

Could this absence be related to a disability? *

(if yes then consider whether any reasonable adjustments would assist them)

Is the employee now fit to undertake all duties? *

If not; what duties are they able to undertake? *

Did the employee seek advice from their GP/ have they been referred to a Consultant? *

If so are they receiving any medication and/or require further treatment? *

Is the employee returning to a temporary or modified role? *

Occupational aware required:

Describe temporary or modified role and location: *

Anticipated date of return to full duties in substantive role: *

Is the employee aware of their personal responsibility to maintain their own health? *

Have you discussed any health awareness information or the employee signposted to information? *

If yes what what discussed? *

Agreed Actions by Employee: *

Timescale/ Review Date: *

Agreed Actions by the Manager: *

Timescale/ Review Date: *

Does the employee have any concerns about any work related issues, which may have a bearing on their sickness absence? *

Has the employee been referred to Occupational Health? If so what was the advice? If no, consider whether a referral is required: *

Any other comments/recommendations/actions required? *

Total number of working days absence on this occasion: *

Total number of episodes in the last rolling 12 months: *

Does this latest episode require any further action under the Sickness Policy: *

Which stage needs to be triggered? *

(If trigger points have been reached or exceeded, (refer to employee sickness record,) the employee should be made aware that they will be invited to a formal review meeting)

This section must be signed by both the manager and the employee as a true and accurate record of the discussion that took place during the return to work interview.

Manager’s / Supervisor’s Signature: *

Clear Signature

Date *

Employee’s Signature: *

Clear Signature

Date *

Any additional iinformation: *

Phone Number

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