Return to Work Interview

This section of the form MUST be completed by the line manager.

Name: / Job Title: / Dept:
Return to work
date: / Return to work interview
date:
Number of working days lost due to sickness:
Number of working hours lost due to sickness:
Number of calendar days lost due to sickness:
If this absence exceeds 7 calendar days, has a YES/NO
medical certificate/fit to work note been provided:
Reason for absence:

This section of the form must be completed by the line manager in the presence of the staff member.

  1. Explain the purpose of the return to work interview, Trust Policy on monitoring, managing sickness absence and give any assistance required to aid staff upon their return to work.
  1. Does the staff member have any problems or concerns relating to their return to work and carrying out the duties of their post? If yes, please give details below:

…………………………………………………………………………………………………………

………………………………………………………………………………………………………….

  1. Does the staff member need / want any assistance or information, e.g., from Occupational Health or HR? Has the member of staff consulted their GP?
  1. Briefly discuss the impact of the staff member’s period of absence, on themselves, their department and the Trust.
  1. Discuss the employee’s sickness absence record to date (the past rolling 12 months):

Number of occasions over last rolling 12 months:
Total number of working day’s lost in last rolling 12 months:
  1. Has the staff member followed the correct procedure for sickness absence reporting? YES/NO

If NO, please give details below:

…………………………………………………………………………………………………………..

7. Any previous formal sanctions in place: YES/NO

If YES, what was the date and give details?

…………………………………………………………………………………………………………

8. Any further action in respect of the Trusts Attendance Management Policy: YES/NO

e.g. Referral to next stage.

If YES, specify in summary of return to work interview below:

SUMMARY OF RETURN TO WORK INTERVIEW

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  1. Is Occupational Sick Pay to be withheld? YES/NO

If YES, please specify the reason why:

………………………………………………………………………………………………………………………….

10. Is an occupational health referral required? YES/NO

If YES, please give reasons:

………………………………………………………………………………………………………………..

Line Manager’s Name (print): ………………………………………………………

Line Manager’s Signature: ………………………………………………………….

Post Title: …..…………………………………………………………………..

Date: ……………………………

If Occupational Sick Pay is to be withheld you must inform payroll immediately.

RESEARCH MATTERS AND SAVES LIVES - TODAY’S RESEARCH IS TOMORROW’S CARE

Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care. We are actively involved in undertaking research to improve treatment of our patients. A member of the healthcare team may discuss current clinical trials with you.

Chairman: Mr Ian Johnson M.A., LL.M.

Chief Executive: Mr Gary Doherty