Return to work Return To Work Name of Absentee First Last Name of person completing form First Last Reason for Absence*Illness/AccidentTransport issueRota IssueDate of first absent shift* Date Format: DD slash MM slash YYYY Date of last absent shift* Date Format: DD slash MM slash YYYY Questions to askAre any amendments to the workplace needed upon your return?*NoYesProvide the amendments needed.*Are there any medication we need to be aware of?*NoYesProvide the medication names and dose*Are you fit for work?*NoYesSignature of Absentee*Signature of person filling out form*Privacy* By using this form you agree with the storage and handling of your data by this website. * NameThis field is for validation purposes and should be left unchanged.