Back To Work

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

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 *

Clear

If you are human, leave this field blank.

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(18+)

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(1+)

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(Women 16-64 Yrs)

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(1-17 Years)

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(12+)

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(5+)

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(1+)

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