Return to Work Form

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Return To Work Form BUK.SHEQ.FO.005.2

Name(Required)

Department

Absence start date(Required)

Absence end date(Required)

Number of days(Required)

Who did you report your absence to?(Required)

Date(Required)

Time(Required)

How did you report your non attendance?(Required)

State briefly why you were unfit for work) specify nature of illness or injury.(Required)

Do you now consider myself fit for work?

Yes

Any other comments