Return to Work Interview

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Neath, Port Talbot and Swansea
POPS

The aim of the return to work interview is:

To ensure the employee is up to date with work or re-allocation of work during their absence.
To assist the community support manager to identify where they can help or take action to help prevent a further recurrence of sickness absence.

The Interview must be held within two days of the employee returning to work and this form should be forwarded to Administration once completed.

Please note: The information on this form is likely to be considered as sensitive data and as such needs to be processed under the provisions of the Data Protection Act. Therefore, information contained in this document will be treated as strictly confidential and kept in the employee’s personnel file.

Employee Name:*

Email*

Location:

Self-Certificate/Statement of Fitness for Work attached?

Yes
No

If you have a Self-Certificate/Statement of Fitness for Work you can upload it below.

Please upload a Self-Certificate/Statement of Fitness for Work

Drop files here or

Max. file size: 256 MB.

Total days absent from work:

First day of absence:

Date returned to work:

Last recorded absence:

Number of absences to date:

Reason for absence:

Was the absence related to an accident at work?

Yes
No

Was the absence related to an accident at work - Comments

If yes, was it reported?

Yes
No

If yes, was it reported - Comments

RTW discussion notes – to be completed By Community Care Manager

First day of shift/session hand back:

Date returned to work:

Reason for hand back:

RTW discussion notes – to be completed By Community Care Manager:

Total number of days sick:

Total number of absent periods:

Total number of shift hand backs:

Bradford Score Record:

Further Action Required?

Note: If further action is required, please arrange a meeting to discuss the matter with senior management.

Yes
No

Employee Name:*

Employee Signature*

Employee Date Signed:*

Supervisor Name:*

Supervisor Signature*

Supervisor Date Signed:

Do you have any questions?

Please note: The information on this form is likely to be considered as sensitive data and as such needs to be processed under the provisions of the Data Protection Act. Therefore information contained in this document must be treated as strictly confidential and kept in the employee’s personnel file.

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Neath Port Talbot/Swansea

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Neath Port Talbot/Swansea