Return to Work Interview Form
Notes for line managers
1. Please complete this form [electronically] after discussion with the employee returning from sickness
absence, print a hard copy ensuring that it is signed and dated by both of you.
2. Please then scan the form and send it electronically to your HR Officer.
3. Further information and guidance can be found at Section 4.1 “Return to Work Interviews” of the
School’s Sickness Absence Procedure and in the supporting Guidelines for Managers.
Name of employee
Job Title / Section / Department
Name of employee’s line manager
Date of Return to Work Interview
First date of the employee’s absence
Date of the employee’s return to work
Reason for the sickness absence
Did the employee properly notify the employer of
his/her absence in accordance with Section 3.2 of Yes No
the Sickness Absence Policy?
Did the employee consult his/her GP? Yes No
Did the employee indicate that factors at work may
have caused or contributed to the absence?
If yes, please explain reasons
If so, what action is to be taken to support the
Was the absence related to a disability? Yes No
If yes, what action is to be taken to support the
Any further comments from the line manager?
Is a referral to Occupational Health required? Yes No
Signature of employee
Signature of line manager
HR Directorate – February 2012