Welcome Back to Work Form (Sickness)
The line manager should use this form to record a conversation about a colleague’s absence at the start of their first
shift back.
Colleague Name Position
Practice Completed By (Name
of Manager)
ACTIONS PRIOR TO MEETING
Check previous absence records for the last 12 months including medical and disciplinary records
Number of previous occasions in past 12 months:
What reason was given when the absence was
first reported?
Who was it reported to?
THE MEETING
st
Date of 1 day of Date of Duration:
absence return
to work
REASON FOR ABSENCE SYMPTOMS/ FURTHER DETAILS
Nature of absence?
If the absence is due to an accident at work,
please provide further detail.
Was the accident reported as per policy?
Did you seek professional help (e.g., GP), if so,
what advice was given?
Have you suffered from this illness before?
Is the absence related to an ongoing medical
condition, if so, please give details.
Is the absence likely to reoccur?
Are there any follow up medical
appointments required and if so, please give
details.
Did you take or are you continuing to take any
medication, if so, what are these and are
there any known side effects?
Are there any adjustments we could make to
support you in work? If yes, please give
details.
Do you feel sufficiently recovered to return to
work?
Do you feel generally happy in work or is
there anything that you would like to discuss
with me?
Any further information?
Has a self-certification form been completed Y N
if the absence is less than 7 days?
Has a fit note been provided for absences Y N
over 7 days?
Was the absence reported as per company Y N
guidelines?
If no, ask the colleague to tell you the absence reporting
procedure and make any corrections.
COLLEAGUE DECLARATION
By signing this form, I am declaring that the information contained on this statement is true and complete
and that I was absent from work because of an illness/injury or incident which was serious enough to prevent
me from working. Furthermore, I understand that should these details prove incorrect, disciplinary action
may be taken which could affect my sick pay and lead to my dismissal.
Manager’s Name Manager’s Signature Date
Colleague’s Name Colleague’s Signature Date
If you have any concerns or need advice about the information above, then please contact the People Advisor Team
on 01793 429032.
If the colleague is returning from a period of long-term sick, then please complete this document and advise the
People Advisor Team accordingly.
Absences within a rolling 12-month period may potentially trigger warning levels (depending on individual
circumstances). If this is the 3rd occasion of absence, please complete an Attendance Review Form. Once complete,
please contact the People Advisor Team to discuss.
Please update the Absence Calculator form and refer to the absence policy if necessary.
On Your Reward Hub, you can access the Wellbeing Centre for money tools, a budget planner, loan calculator and financial
info on budgeting, spending, credit and borrowing. We have links to financial support available to colleagues, easy access
savings and loans via ‘Save as you Borrow’ loans, links to financial aid and access to our Colleague Hardship Fund for a
nonrepayable grant. Within the Wellbeing Centre, you can also access the "mind” section for online meditation, better sleep
tutorials, soundscapes, and articles. We provide access to counselling and information on managing mental health, self-care,
managing stress, domestic abuse, loneliness, low self-esteem, bereavement, managing anger, eating disorders, self-harm,
parenting, relationship breakdowns, and much more. Through our partnered charities we also provide access to helplines,
talking therapies, peer support, advocacy, crisis care, employment, and housing support.
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