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Employee Relations
Return-to-Work Interview Form
A form for conducting a return-to-work discussion after a period of absence, assessing health status, work readiness, adjustments needed, and follow-up plan.
RETURN-TO-WORK INTERVIEW FORM
Employee: [Name] | ID: [Number]
Absence Dates: [From] to [To]
Date of Return: [Date]
Meeting Date: [Date]
1. REASON FOR ABSENCE
[Employee explanation]
2. CURRENT HEALTH STATUS
☐ Fit to resume full duties
☐ Fit with adjustments — Specify: [Adjustments]
☐ Needs further time off (attach medical certificate if applicable)
3. WORK READINESS
☐ Ready to resume normal duties
☐ Needs phased return — Schedule: [e.g., half days for week 1]
☐ Needs temporary adjustments — Specify: [e.g., reduced hours, no heavy lifting]
4. ANY OUTSTANDING ISSUES
[Any workplace concerns the employee wishes to raise]
5. MANAGER NOTES
[Observations and agreed next steps]
6. ACTION PLAN
[Agreed actions between manager and employee]
1. [Action]
2. [Action]
3. [Action]
FOLLOW-UP
Check-in scheduled: [Date]
Additional support needed: [Details]
Employee Signature: ___________________ Date: _______
Manager Signature: ___________________ Date: _______
HR notified: ☐ Yes — Date: [Date]