Template

Return to Work Form Checklist for Critical Workers

10+

Use this return to work form to assess employees returning after sickness or exposure across critical infrastructure sectors. Capture employee details, absence dates, reasons for illness, and meeting notes. Follow worker and employer steps including masking, distancing, symptom and temperature checks, routine cleaning, increased air exchange, and staggered breaks. Includes sign off for employee and manager and aligns with CDC guidance for critical workers.

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Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

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Free 1,000+ Workplace Checklists & Templates created by the SafetyCulture team.

Template
Return to Work Form Template
Use this employee return to work form to document absence dates and reasons, confirm notification procedures, review previous sickness records, and plan a safe reintegration. Sections include employee and manager details, dates of absence and return, reason for absence, contact and reporting compliance, prior absences in the last 6 and 12 months, and an action plan outlining agreed adjustments, review dates, and comments. The form concludes with employee and manager signatures to confirm understanding and next steps. Intended as a general example; verify suitability for your workplace and jurisdiction.
by Kim Gaston, from the Community
Downloads: 10+
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Template
Return to Work Checklist
Streamline employee reintegration after illness or injury with a structured return to work checklist for transport and rail teams. Capture location, manager and employee details, dates of sickness and return, reasons for absence, and total days off. Verify reporting procedures, self-certification, and fit notes, and record medical advice, prescribed medication, and notification forms. Assess business impact, reference attendance procedures, and document accidents or annual leave overlaps. Plan rehabilitation steps, welfare or counseling services, and actions to prevent recurrence, with signatures from both employee and manager.
by Ray Upton, from the Community
Downloads: 0
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Template
Return to Work Form BCS
This Return to Work form helps managers document employee sickness absence and the steps taken before returning. Capture dates of absence, reasons, medical attention, and any links to previous incidents. Verify compliance with reporting procedures, note accident at work details, and track certificates for absences over seven days. Includes health screening questions, declarations, and signatures for both employee and manager. Built by Bulloughs Cleaning Services and suitable for cleaning operations, yet adaptable across industries.
by Sally Taylor, from the Community
Downloads: 10+
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Template
Return to Work Form
Use this return to work form to conduct effective interviews after an employee absence. Confirm reasons for absence, assess fitness to return, plan phased schedules if required, and capture agreed actions and timelines. Record sensitive information appropriately, note any GP fit notes, and route the completed form to HR for logging. Suitable for HR teams and people managers across industries.
by Agnes Schooling, from the Community
Downloads: 10+
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Return to Work Form Template

Use this employee return to work form to document absence dates and reasons, confirm notification procedures, review previous sickness records, and plan a safe reintegration. Sections include employee and manager details, dates of absence and return, reason for absence, contact and reporting compliance, prior absences in the last 6 and 12 months, and an action plan outlining agreed adjustments, review dates, and comments. The form concludes with employee and manager signatures to confirm understanding and next steps. Intended as a general example; verify suitability for your workplace and jurisdiction.

by Kim Gaston, from the Community

10+

Get

Template

Return to Work Checklist

Streamline employee reintegration after illness or injury with a structured return to work checklist for transport and rail teams. Capture location, manager and employee details, dates of sickness and return, reasons for absence, and total days off. Verify reporting procedures, self-certification, and fit notes, and record medical advice, prescribed medication, and notification forms. Assess business impact, reference attendance procedures, and document accidents or annual leave overlaps. Plan rehabilitation steps, welfare or counseling services, and actions to prevent recurrence, with signatures from both employee and manager.

by Ray Upton, from the Community

Get

Template

Return to Work Form BCS

This Return to Work form helps managers document employee sickness absence and the steps taken before returning. Capture dates of absence, reasons, medical attention, and any links to previous incidents. Verify compliance with reporting procedures, note accident at work details, and track certificates for absences over seven days. Includes health screening questions, declarations, and signatures for both employee and manager. Built by Bulloughs Cleaning Services and suitable for cleaning operations, yet adaptable across industries.

by Sally Taylor, from the Community

10+

Get

Template