Return to Work Interview

Complete the form below to document an employee's return to work.

Return to Work Form

Please fill in all the details accurately.

Employee

Absent From

End of Absence

Reason for absence

Was a health professional consulted?

Yes

No

Are you on any medication as a result?

Yes

No

Do you feel that you are able to return to work and perform your duties satisfactorily?

Yes

No

Not Sure

Is there anything the company can do to assist you?

Employee Signature

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