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Free Return to Work Form Template

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RETURN TO WORK INTERVIEW FORM
Acme Manufacturing Ltd  ·  Equality Act 2010 · MHSW Regs 1999 · UK GDPR Art.9
INTERVIEW AND PARTIES
ORGANISATIONAcme Manufacturing Ltd, Unit 7, Broadoak Industrial Estate, Sheffield S9 1YT
CONDUCTING MANAGERSarah Elizabeth Johnson — Operations Line Manager (sarah.johnson@acme-mfg.co.uk)
DEPARTMENTOperations — Warehouse
INTERVIEW DATE2026-03-28
INTERVIEW LOCATIONMeeting Room 2, Acme Operations Building
EMPLOYEE
EMPLOYEEJames Peter Williams (No. ACME-2041)
JOB TITLEWarehouse Operative
CONTINUOUS SERVICESince 2022-01-04
ABSENCE RECORD
ABSENCE START2026-03-16
RETURN DATE2026-03-28
TOTAL CALENDAR DAYS12
WORKING DAYS ABSENT9
REASONAccident / Injury
FIT NOTE PROVIDEDYes — provided by a registered healthcare professional — May be fit for work with adjustments (if your employer agrees)
FIT NOTE ADJUSTMENTSAvoid heavy lifting over 5 kg for two weeks; phased return recommended
This Return to Work Interview Form (this "Form") records the discussion held on 2026-03-28 between Sarah Elizabeth Johnson (for Acme Manufacturing Ltd) and James Peter Williams. Its purpose is to welcome the employee back after absence, identify any work-related causes or ongoing health issues, and agree any adjustments, support or follow-up needed for a safe and sustainable return, in accordance with ACAS guidance on managing absence and the employer's absence-management policy.
1.
ABSENCE SUMMARY
The absence lasted 12 calendar days (9 working days) from 2026-03-16 to 2026-03-28. The reason recorded for the absence was Accident / Injury. Detail: Acute lower-back strain following a lifting incident during packing duties on 15 March 2026. Accident recorded in the Company accident book (entry AM-8821).. Fit note: Yes — provided by a registered healthcare professional. The fit-note certification stated: May be fit for work with adjustments (if your employer agrees). Fit-note adjustments suggested by the GP / treating clinician: Avoid heavy lifting over 5 kg for two weeks; phased return recommended. Absences of seven (7) days or fewer are self-certified; longer absences require a "Fit for Work Statement" (fit note) from a registered healthcare professional (GP, nurse, pharmacist, occupational therapist or physiotherapist).
2.
CONFIRMATION OF FITNESS TO RETURN
The employee confirms that they are fit to resume their duties as Warehouse Operative, subject to any adjustments recorded in this Form. Both parties acknowledge their respective duties under the Health and Safety at Work etc. Act 1974 (employer's general duty under s.2; employee's duty under s.7), the Management of Health and Safety at Work Regulations 1999 (risk assessments under reg 3) and, where relevant, the Display Screen Equipment Regulations 1992. The employee undertakes to notify the Employer without delay of any material change in their health or ability to perform the role safely, and the Employer undertakes to respond promptly and fairly. Nothing in this Form subjects the employee to detriment for raising health-and-safety concerns, which is protected by ERA 1996 s.44.
3.
IMPACT OF ABSENCE ON WORK AND TEAM
The following operational impact, team cover and service-delivery issues were discussed and recorded: Packing rota reorganised; two overtime shifts required to meet dispatch deadlines; back-up operative called in from agency for 3 shifts. This section is for management-learning purposes; it is not a disciplinary record and does not form part of the employee's capability or conduct file.
4.
EMPLOYEE HEALTH DECLARATION (SPECIAL-CATEGORY DATA)
The employee made the following voluntary statement regarding current fitness to perform the role: Employee feels fit to return to work on light duties only; back is improving; exercising care with lifting; attending physiotherapy once per week. Information provided in this clause is special-category data (health data) within Article 9 UK GDPR. It is processed on explicit consent under Art.9(2)(a) UK GDPR, only for absence management and the assessment of any reasonable adjustments, on a strict need-to-know basis, and retained in accordance with the Employer's Data Retention Policy.
5.
DISABILITY STATUS NOT DISCLOSED
The employee has not disclosed whether the absence relates to a condition which may be a disability under the Equality Act 2010. Nothing in this Form prevents the employee from making such a disclosure at any time, in which case the Employer will reconsider reasonable adjustments promptly.
6.
WORKING HOURS, DUTIES AND WORKPLACE ADJUSTMENTS
The following temporary adjustments to working hours, duties or workplace have been agreed to support the safe return of the employee: Restricted to picking duties (no items over 5 kg) for two weeks; standing desk for paperwork tasks; regular 10-minute breaks every 90 minutes. Where the employee meets the definition of disability under the Equality Act 2010, these adjustments are made in discharge of the reasonable-adjustments duty under ss.20-21. Adjustments may be varied by agreement as the employee's position progresses.
7.
RIDDOR NOTIFICATION
The absence followed a work-related accident or incident. As the absence exceeded seven (7) consecutive days (not counting the day of the accident), the Employer has made or will make a report to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) reg.4. A risk-assessment review has been or will be carried out under MHSW Regs 1999 reg 3.
8.
SUPPORT PLAN
The following support measures have been agreed:

Occupational Health (OH) Referral. The employee will be referred to the Employer's OH provider for an independent assessment and, where appropriate, advice on adjustments, phased return and prognosis. The employee has consented in writing to an Occupational Health referral.

Phased Return to Work. A phased-return schedule will be agreed in writing, with a gradual increase in hours and/or duties over an agreed period. Proposed plan: Week 1: 4 hours per day × 5 days (light duties); Week 2: 6 hours per day × 5 days; Week 3: full hours and full duties subject to OH review.

Employee Assistance Programme (EAP). The employee has been reminded of the confidential EAP service covering counselling, wellbeing and legal / financial guidance.
9.
FOLLOW-UP AND REVIEW
A follow-up review has been scheduled for 2026-04-11 to check progress and review any agreed adjustments or support. Day-to-day welfare contact: Maria Delgado (Deputy Line Manager). Escalation note: Escalate to HR Business Partner (Helen Murray) if pain increases or physiotherapy extends beyond 4 weeks.

Additional notes: Manual-handling refresher training booked for 8 April 2026. Employee acknowledged existing accessibility of manual-handling e-learning module (course ref MH-001)..
10.
DATA PROTECTION AND CONFIDENTIALITY
The Employer will process information recorded in this Form in accordance with the UK GDPR, the Data Protection Act 2018 and the Employer's privacy notice. Health information recorded in this Form is special-category data within Article 9(1) UK GDPR and is processed on the employment, social-security and social-protection condition in Art.9(2)(b), read with DPA 2018 Sch 1 Pt 1 para 1, or where appropriate on explicit consent under Art.9(2)(a). Access is restricted on a need-to-know basis. The Form will be retained for the period set out in the Employer's data-retention schedule and thereafter securely deleted or anonymised.
11.
STATUTORY RIGHTS
Nothing in this Form excludes or limits any statutory right of the employee, including: protection from unfair dismissal (ERA 1996 ss.94-98); protection from disability, pregnancy / maternity or other prohibited discrimination (Equality Act 2010); the right to be paid not less than the National Minimum / Living Wage (NMWA 1998); the right not to suffer unauthorised deductions from wages (ERA 1996 s.13); protection from detriment for raising a health-and-safety concern (ERA 1996 s.44); and the right to make a protected disclosure under the Public Interest Disclosure Act 1998.
CONDUCTING MANAGER
2026-03-28
Operations Line Manager
Sarah Elizabeth Johnson
Date: ____________________
EMPLOYEE
2026-03-28
Employee — acknowledging receipt, not the content
James Peter Williams
Date: ____________________

What Is a Return to Work Form?

A return-to-work form is a document completed when an employee comes back to work after a period of absence, typically due to illness. It records the details of the absence, any ongoing health concerns, and any support or adjustments needed to help the employee return successfully.

While there is no specific legal requirement to conduct a return-to-work interview, ACAS recommends it as one of the most effective tools for managing short-term absence. It shows employees that their absence is noted and that the employer cares about their wellbeing.

A structured UK return-to-work process helps British employers identify patterns of absence, fulfil their duty of care, and ensure compliance with the Equality Act 2010 in England and Wales where the absence relates to a disability or long-term health condition under English employment law.

What's Covered in This Template

Our return-to-work form template covers all the key areas for a thorough and supportive return-to-work discussion.

Employee Details

Full name, job title, department, and employee reference number.

Absence Dates

First day of absence, last day of absence, and total working days missed.

Reason for Absence

The nature of the illness or reason for absence, as reported by the employee.

Fit Note Details

Whether a fit note was provided and any recommendations from the employee's GP.

Current Health Status

Whether the employee feels fit to return to their full duties or requires any temporary adjustments.

Reasonable Adjustments

Any workplace adjustments needed, such as phased return, modified duties, or ergonomic changes.

Absence History

A summary of the employee's absence record over the relevant review period.

Trigger Point Review

Whether the absence has triggered any formal review under the company's absence management policy.

Support Offered

Any wellbeing support, occupational health referral, or employee assistance programme details discussed.

Manager and Employee Signatures

Signatures confirming the discussion took place and both parties understand any agreed actions.

How to Create a Return to Work Form

Follow these steps to complete a return-to-work form using our template.

  1. 1

    Enter Employee and Absence Details

    Fill in the employee's name, job title, and the dates of their absence, including the total number of working days missed.

  2. 2

    Record the Reason for Absence

    Note the reason for absence as described by the employee. If a fit note was issued, record the GP's recommendations regarding fitness to work.

  3. 3

    Discuss Fitness to Return

    Confirm whether the employee feels fully fit or whether any temporary adjustments are needed. Record any agreed changes to duties, hours, or workplace arrangements.

  4. 4

    Review Absence History

    Check the employee's absence record against the company's absence management triggers. If a trigger has been reached, note what formal steps will follow.

  5. 5

    Sign and File

    Both the manager and employee should sign the form. Download it as a PDF and file a copy in the employee's personnel record.

Legal Considerations

Return-to-work discussions intersect with several areas of UK employment law.

This template is for informational purposes only and does not constitute legal advice. Consult a qualified solicitor for advice specific to your situation.

Reviewed for England & Wales law

Equality Act 2010 — Reasonable Adjustments

If a UK employee's absence is related to a disability under the Equality Act 2010, the British employer has a duty to make reasonable adjustments to remove or reduce any disadvantage. This may include a phased return, modified duties, changes to working hours, or physical workplace modifications in England and Wales. Failure to make reasonable adjustments is a form of discrimination under English law.

Fit Notes and GP Recommendations

Since 2010, the UK medical certificate (fit note) allows British GPs to declare an employee either "not fit for work" or "may be fit for work" with certain adjustments. UK employers should give serious consideration to the GP's recommendations. Ignoring a fit note's advice without good reason could undermine the fairness of any subsequent management action under English employment law.

Data Protection

Information about a British employee's health is special category personal data under the UK GDPR and Data Protection Act 2018. It must be processed lawfully in England and Wales, kept confidential, and only shared with those who need to know. UK return-to-work forms should be stored securely and separately from general personnel files where appropriate.

Statutory Sick Pay

UK employees who meet the qualifying conditions are entitled to Statutory Sick Pay for up to 28 weeks under British employment law. SSP is paid from the fourth qualifying day of sickness absence in England and Wales. The UK return-to-work form can help confirm the dates of absence for payroll purposes and ensure SSP records are accurate.

Frequently Asked Questions

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