RETURN TO WORK INTERVIEW FORM

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THIS FORM IS TO BE COMPLETED PRIOR TO RETURNING TO WORK. PLEASE DO NOT COME INTO WORK AND THEN FILL IT OUT. Each question in this form is mandatory. If it does not relate to you please fill in with N/A. Nova Products Global reserves the right to use this information in relation to your employment if deemed necessary. Novaproducts requires 12 hours to process your request to return to work . If you receive no contact within this period then you are free to return to work. If you are happy with this please continue .
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Name
First Name
Last Name
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Phone Number (if your number has changed from previous please advise on return)
Area Code
Phone Number
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Email
example@example.com
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Position (Type Factory, Site or Office)
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Start date of absence from work* This field is required.
Date
Year
Month
Day
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Please write a detailed reason for absence and whether is it likely to be a recurring issue.
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If yes, do you have any follow up appointments scheduled with the Medical Practitioner or Specialist?
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If you visited a Medical Practitioner please up load a copy of the report below.
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Did you require to be admitted to the hospital?* This field is required.
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Do you require any support or modified arrangements at work ? If yes, what type of support? (please note if yes you will need to wait for our approval to return to work regardless of time frames).
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Are you completely fit for return to all duties at work and if not please explain what restrictions you have? (we will require a Medical Certificate stating your capacity and will need to agree to your return prior to you returning to the workplace).
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To your knowledge, is your sickness contagious? (We advise Viewing HEALTH DEPT online for information. If you have had Gastro or viruses you may not be fit for work for at least 48 hours after your last symptom - check with your Medical Professional as we may not accept you back to work)
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Type a questionWas your sickness anything to do with a condition prior to working for Novaproducts?
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Do you feel impaired or lethargic? Has your medications changed since you last advised us? Do you take medication that may interfere with yours and everyone's safety?
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Do you currently have any remaining symptoms from recent sickness? For example: stomach pains, nausea, migraine, feeling faint etc. If so, please describe your symptoms.
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Commentsi.e. (what actions has the employee agreed to in order to avoid further absence and any employer action?)
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Supporting Documents* This field is required.For sickness we always require a Medical certificate from your GP, Chemist or a Statutory Declaration etc
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Signature (Employee)
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Should be Empty: