Free Return to Work Form Template

RETURN TO WORK INTERVIEW FORM

Acme Manufacturing Ltd  ·  Equality Act 2010 · MHSW Regs 1999 · UK GDPR Art.9

INTERVIEW AND PARTIES

EMPLOYEE

ABSENCE RECORD

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.

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).

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.

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.

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.

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.

The Employer reminds the employee of the following statutory family-friendly leave rights, which may be relevant on return:

(a) Carer's leave: a day-one right to take up to one (1) week of unpaid leave per rolling twelve-month period to provide or arrange care for a dependant with a long-term care need, under the Carer's Leave Act 2023 and the Carer's Leave Regulations 2024 (SI 2024/251) (in force 6 April 2024);
(b) Neonatal care leave and pay: where the employee has a baby admitted to neonatal care, the employee is entitled to up to twelve (12) weeks of paid neonatal care leave (in addition to maternity / paternity / adoption leave), under the Neonatal Care (Leave and Pay) Act 2023 and Regulations 2025 (in force 6 April 2025);
(c) Bereavement leave: statutory parental bereavement leave and pay (two weeks following the death of a child under 18 or a stillbirth after 24 weeks) under the Parental Bereavement (Leave and Pay) Act 2018;
(d) Flexible working: a day-one statutory right to request flexible working (up to two requests in any twelve-month period) under sections 80F-80I of the Employment Rights Act 1996, as amended by SI 2023/1328 and the Employment Relations (Flexible Working) Act 2023.

The Employer reminds the employee of its proactive duty to prevent sexual harassment of workers under section 40A of the Equality Act 2010 (introduced by the Worker Protection (Amendment of Equality Act 2010) Act 2023, in force 26 October 2024). The Employer's anti-harassment policy and reporting routes will be re-shared, and the employee is invited to raise any concerns about treatment by colleagues, customers or third parties — whether before, during or on return from absence — through HR or a designated speak-up channel without fear of detriment. The Employer will take the disclosure seriously and act on it under the relevant policy.

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.

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.

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.

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)..

The Employer will process information recorded in this Form in accordance with the UK GDPR, the Data Protection Act 2018 and the Data (Use and Access) Act 2025 (as commenced by SI 2026/82 with effect from 5 February 2026), and with 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.

International transfers. Any onward transfer of the employee's health data to a third country (for example, where the Employer's HRIS, OH provider or document-storage service is hosted outside the UK) shall comply with the data protection test in Schedule 7 of the DUA Act 2025 (which replaces the prior "essentially equivalent" standard for adequacy assessments), using an approved transfer mechanism (UK adequacy regulations, the UK International Data Transfer Agreement or UK Addendum to the EU SCCs).

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.