What is it?
A phased return to work form is a form that enables employees to gradually resume their regular duties or full-time jobs after a long sick or injury leave. Filling out this form will assist a company in gently reintroducing employees to their regular work schedules by making proper adjustments to their work plans.
When to use?
Consider using this phased return to work form template anytime you have an employee who wants to gradually resume their regular duties after a long sick or injury leave. Having this template on hand will help you to easily create a resumption schedule as well as make the overall process more repeatable and efficient.
What to include?
- Employee information
- Date
- Employee working hours
- Reasons for long absence
- Normal working pattern
- New working pattern
- Additional information
- Signatures
Date returned to work |
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Employee information |
First name |
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Middle name |
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Last name |
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Contact information |
Phone number |
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Email address |
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Job information |
Department |
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Job title |
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Working hours (Kindly tick correctly) |
Full time |
Part time |
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First date unfit for work |
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Last date unfit for work |
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Reasons for long absence? |
Sickness |
Accident |
Maternity |
Other |
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Normal working hours pattern |
Days of the week |
SUN |
MON |
TUE |
WED |
THU |
FRI |
SAT |
Numbers of working hours |
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New working hours pattern |
Week 1 |
Numbers of working hours |
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Week 2 |
Numbers of working hours |
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Week 3 |
Numbers of working hours |
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Week 4 |
Numbers of working hours |
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Additional information |
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Employee signature |
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Manager signature |
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