Return to work Return To Work 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 askAre 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*PhoneThis field is for validation purposes and should be left unchanged.
