Name of Absentee
First
Last
Name of person completing form
First
Last
Reason for Absence
*
Illness/Accident
Transport issue
Rota Issue
Date of first absent shift
*
DD slash MM slash YYYY
Date of last absent shift
*
DD slash MM slash YYYY
Questions to ask
Are any amendments to the workplace needed upon your return?
*
No
Yes
Provide the amendments needed.
*
Are there any medication we need to be aware of?
*
No
Yes
Provide the medication names and dose
*
Are you fit for work?
*
No
Yes
Signature of Absentee
*
Signature of person filling out form
*
Name
This field is for validation purposes and should be left unchanged.