Return To Work Form

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{company_phone}} | Email: {{company_email}} | Website: {{company_website}}

Employee Information

Employee Name: {{employee_name}}

Employee ID: {{employee_id}}

Department: {{department}}

Position: {{position}}

Contact Number: {{contact_number}}

Email Address: {{employee_email}}

Leave Details

Type of Leave: {{type_of_leave}} (e.g., Sick Leave, Maternity Leave, Annual Leave, Unpaid Leave)

Last Day of Work: {{last_day_of_work}}

Date Leave Commenced: {{leave_start_date}}

Anticipated Return Date: {{anticipated_return_date}}

Actual Return Date: {{actual_return_date}}

Reason for Absence (Optional, for HR records)

{{reason_for_absence}}

Medical Certification (if applicable)

If your absence was due to illness or injury, please attach a medical certificate from a registered healthcare practitioner confirming your fitness to return to work.

Date of Medical Certificate: {{medical_certificate_date}}

Attending Practitioner's Name: {{practitioner_name}}

Contact Number: {{practitioner_contact}}

Declaration of Fitness to Return to Work

I, {{employee_name}}, declare that I am fit to resume my full duties and responsibilities as {{position}} at {{company_name}} starting from {{actual_return_date}}.

I understand that the company reserves the right to request further medical evaluations if deemed necessary.

Special Requirements or Accommodations

Do you require any special accommodations or adjustments to your work environment or duties to facilitate your return to work? (e.g., modified duties, reduced hours, assistive devices). Please specify:

{{special_requirements_details}}

Employee Confirmation

I confirm that the information provided in this form is accurate and complete to the best of my knowledge.

Employee Signature: ____________________________

Date: {{date}}

For Office Use Only (HR Department)

Date Received: {{hr_date_received}}

Reviewed By: {{hr_reviewer_name}}

Return to Work Approved: [ ] Yes [ ] No

If No, Reason: {{hr_rejection_reason}}

Manager Notified: [ ] Yes [ ] No Date: {{manager_notification_date}}

Notes/Actions Taken:

{{hr_notes}}

Signature Block

_____________________________

HR/Line Manager Signature

{{hr_manager_name}}

{{hr_manager_position}}

Date: {{hr_manager_signature_date}}