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Back To Work

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Back To Work

Employee Name *

Employee Email Address *

They will receive a copy of this form

Absence Start Date *

Absence End Date *

Reason For Absence *

Is the Employee capable of returning to work and working effectively? *

Yes

No

In the short term

In the long term

How lack of capability is to be dealt with

Strategy for avoiding further absences for the same or similar reasons

Any agreement reached in order to avoid the possibility of further supervision or disciplinary action due to repeated absence in the future (if any)

Other manager’s comments on this incidence of absence

Date

Signed by Supervisor *

If you are human, leave this field blank.

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LEARN ABOUT OUR ORGANIZATIONS

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