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Self Certificate Return to Work

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					                                                                                Appendix 4




                           RETURN TO WORK INTERVIEW


  AN INTERVIEW MUST BE UNDERTAKEN FOLLOWING EVERY OCCASION OF
                        SICKNESS ABSENCE


NAME……………………………………                           Ward/Dept ……………...………….…………

Job Title…………………………………..                     Hours of Work ……..………………..……….

Manager/Nominated Officer.…………………………………….………….……….…………

DID THE EMPLOYEE:
Comply with local reporting arrangements?                                 Yes     No

Report to the Manager or Nominated Officer before start time or, where    Yes     No
impracticable, within two hours of shift start?
Submit a self-certificate with reasons for absence stated?                Yes     No

Give expected duration of Absence?                                        Yes     No

If you have answered ‘no’ to any of the above note any reasons/explanations and any
follow-up action taken:




Date of First Day of Absence:


(NB If employee sent home sick the following day is the first day of sickness absence)

Please indicate if Uncertified or Certified Sickness

                Self Certificate   □            Medical Certificate   □
Last Day of Absence:

Duration of Absence (total calendar days):


Give Brief Details of the Reason for Absence:
                                                                                 Appendix 4




                RETURN TO WORK INTERVIEW                  (cont’d …….)

This section is to be completed with the employee during the discussion at
the Return to Work Interview.

Is the member of staff fully recovered?                                    Yes       No

If’ no’ please explain health condition and any factors associated with
return to work arrangements:




If phased return to work has been agreed by Occupational Health give details of
hours/days /pattern of hours agreed and period after which this will be reviewed :




If reasonable adjustments e.g. to the workplace/duties are to be made give details:




ADDITIONAL COMMENTS OR DETAILS OF FURTHER ACTION e.g. Appointment
with Occupational Health, follow-up meeting to discuss progress, need to arrange formal
interview to discuss sickness absence levels as per Trusts procedure, review of work
arrangements:




Manager Signature:……………………………………..Date…………………………………..


Employee signature:…………………………………….Date……………………..……………

				
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