Absence Self Certification & Return to Work Interview Record

To be completed by the Employee and Line Manager/Supervisor and then scanned/sent to Payroll and HR
Remember: For sickness absence of more than 7 calendar days a Doctor’s Statement of Fitness for Work is required
Employee’s Name: / Department:
Manager’s Name / Employment Start Date:
Sections A TO C are to be completed AND SIGNED by the employee IN THE PRESENCE OF THEIR LINE MANAGER (WHERE PRACTICABLE)
Section A
Date & Time illness/absence began: / Last Date of illness / absence:
(Please state first & last date of illness including non-working days if applicable):
Date of Return to Work: / Total Working Hrs Absence
First Notification to:
Was correct procedure followed? / Yes/No / State method of notification, name of person notified and date and time.
Please circle your normal contracted working days: Mo Tu We Th Fr Sa Su / Contracted working Hrs per day/week (stores):
Doctor’s note received: Yes No (If No why not)?
Section B / Section C (Complete if absence is due to illness)
Reason for Absence - please select from the list overleaf and describe your symptoms / Did you attend:
Hospital? / Yes / No
Clinic? / Yes / No
Doctors? / Yes / No
If YES what treatment did you receive?
If working in a food environment, have you been free of symptoms for 48 hours? Yes/No
Was your illness caused by: / Please state Name and location of Health Care Provider
An industrial disease? / Yes / No
An accident at work? / Yes / No
If so was it reported? / Yes / No
To Whom?
I certify that the information given is complete and correct and I understand that if I provide inaccurate or false information about my absence it may, depending on circumstances, be treated as gross misconduct and result in my dismissal from the Company.
Employee Signature / Date
Section D (To be completed by Line Manager prior to Return to Work Interview)- continue on separate sheet if necessary
Absence History over previous rolling 52 week period (start with most recent period )
Absence Start Date / Absence End Date / No Of
Working Days / Reason For Absence

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Absence Self Certification & Return to Work Interview Record

Sickness Absence Reasons

Arthritis / Epileptic/Fits / Phased Return To Work
Asthma/Breathing / Hayfever / Road Traffic Accident
Back Injury / Headache/Migraine/Vertigo / Sickness
Broken/Fracture Injury / Hypertension/Blood Pressure / Skin Related Illness
Chickenpox/Shingles / Infection / Stroke/Heart Illness
Cold/Flu / Injuries Other / Stomach
Depression/Stress/Anxiety / Miscarriage / Tooth/Abscess
Diabetes / Not Known / Unwell
Doctors Note / Operation/Hospital / Viral Infection
Bradford Factor Score – These are triggers to help manage absence and are not set in stone. These points indicate guideline action that MAY be taken when a trigger point is reached. Please refer to the Company Absence Policy
To calculate the BF take the number of instances of absence in a rolling 12 month period, multiply it by itself and then by the number of actual days of absence. For example 4 instances of absence totalling 9 days would have a score of 4 x 4 x 9 = 144 points
Bradford Factor Trigger Points / 50 points or more and at least 3 occasions / Manager holds a counselling session with the employee.
100-199 points following counselling or further absence / First level warning
200-299 points following first level warning or further absence / Second level warning
300 points upwards, following second level warning. / Dismissal
BF Score
SECTION E (To be completed by the employee’s Line Manager / Supervisor at the RTW Interview in the presence of the employee)
Suggested questions to be covered at Return to Work Interview as appropriate (full interview notes are to be taken):
·  How are you now and are you able to carry out normal hours and duties?
·  Was the Company notified in accordance with the absence notification procedure? If not, why not?
·  When did you see your GP?
·  What did the GP say was wrong?
·  Is there any continuing medical treatment / follow up appointments? If yes, give details and how does this treatment affect you?
·  Have you been referred to a specialist for any investigations?
·  Are you on any medication which may affect your performance?
·  Is this a recurring problem?
·  Were there any other reasons for the absence?
·  Are there any work related problems contributing to the current absence?
·  Are there any underlying circumstances contributing to current absence?
·  Are there any restrictions on the type of work you can undertake as a result of a medical condition or injury?
·  Do you feel that there is anything we can do to support you?
·  Ensure employee is fully advised of consequences of no improvement in absence levels and that this is documented
·  Advise employee of Bradford Factor score
Interview Notes / Action Plan (Continue on a separate sheet of paper if necessary)
Employee’s signature / Date
Manager’s Signature / Date

Please note that occupational sick pay is not paid during employment from 0-9 months.

Please send page 1 to Payroll and the full form to HR to be retained in personal file.

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