Return to Work Interview Form template

2. Employee and absence details

• Employee name: [name]. Job title: [job title]. Department or site: [department/site].
• Line manager completing this form: [manager name and job title].
• First day of absence: [date]. Last day of absence: [date]. First day back: [date].
• Working days lost: [number]. Shifts missed: [number] — record both where staff work variable shifts.
• How the absence was reported, and when: [e.g. phoned the duty manager at 07:20 on the first day of absence, in line with our absence reporting rules].
• Reason given by the employee: [reason in the employee's own words].
• Self-certification completed (absences of 7 days or less): [yes/no — GOV.UK confirms no fit note is needed for 7 days or less].
• Fit note received: [yes/no]. If yes — issued by [GP / hospital doctor / registered nurse / occupational therapist / pharmacist / physiotherapist], dated [date], covering [dates].
• Fit note states: [not fit for work / may be fit for work]. If "may be fit for work", the options indicated are: [phased return / altered hours / amended duties / workplace adaptations].
• Copy of the fit note taken and filed: [yes/no] — the employee keeps the original.
• Absence record for the last 12 months: [number] days across [number] separate occasions. [Note any trigger point reached under our absence management policy.]

3. The interview — complete during the conversation

Work down the questions with the employee and write their answer in their words. The third column is for what happens next and who owns it — leave it blank where nothing is needed rather than inventing an action. The last three rows are free for anything this list does not cover.

4. Agreed adjustments and return plan

• Adjustments or changes agreed: [describe each one — e.g. no lifting over 10kg for four weeks; start an hour later for three weeks; laptop riser and external keyboard ordered].
• Phased return agreed: [yes/no]. If yes — hours or duties for week 1: [detail]; week 2: [detail]; full duties resume on [date].
• Who is arranging each change, and by when: [name] by [date].
• Whether these are being treated as reasonable adjustments under the Equality Act 2010: [yes / no / to be confirmed after occupational health advice]. Where they are, {{org.name}} meets the cost.
• Occupational health or other referral made: [yes/no]. Referred to [provider] on [date]; consent obtained: [yes/no].
• Work-related cause identified: [yes/no]. If yes, what is being reviewed and by whom: [e.g. risk assessment for the packing bench, reviewed by the site manager by the review date].
• Review date for the adjustments and the return plan: [date]. Reviewer: [name].
• Team or rota changes needed as a result: [detail, or "none"].

5. Declaration and signatures

Employee declaration: "I confirm that the absence details above are accurate, that I am fit to return to the duties described, and that I have read what has been recorded on this form. I understand I can add my own comments before signing."

Employee comments: [free text — leave real space here; if the employee disagrees with anything recorded, it goes in this box rather than being argued out of the form].

Employee signature: [signature] Date: [date]

Manager declaration: "I confirm this conversation took place on the date shown, that the responses recorded are the employee's own, and that the actions above have been agreed."

Manager signature: [signature] Date: [date]

Form filed by [name] in [HR system / personnel file location] on [date].

6. Running it as a welfare check, not an interrogation

The tone of this conversation decides what you learn from it. Acas advises employers to make sure the discussion is private and confidential, to gather the relevant records first, to prepare the questions, and to know what support can actually be offered before opening the conversation — because an offer you cannot deliver is worse than no offer. Ten minutes in a side room beats a corridor exchange, and it beats an email.

Ask, then listen. The manager's job is to record what the employee says, not to test it. Challenging a reason across the desk produces shorter answers next time and teaches people to report absence as "not well" and leave it there — which is precisely the information you lose. Where a manager genuinely doubts the honesty of a report, that is a conduct concern to be handled under the disciplinary policy on evidence, not something to litigate on a return to work form.

Two practical rules. Do not ask for a diagnosis — you need to know the effect on the work, not the name of the condition. And do not record more health detail than the actions require: "advised to avoid prolonged standing for two weeks" is the useful line, not a paragraph of medical history.

7. When a pattern triggers the absence procedure

• Record every absence on this form, including single days. Patterns only become visible when short absences are counted; most employers see the frequent absentee late because nobody logged the Mondays.
• Apply the trigger points in the absence management policy consistently — Acas guidance on absence policies says an employer should set out whether a trigger point system is used and how it works, so state it in the policy and follow it for everyone.
• A trigger being reached does not mean discipline. It means a conversation: what is causing this, is it work-related, is support or a referral needed, is an adjustment the answer.
• Note the shape of the pattern, not just the total — absences either side of rest days, repeat absences after a particular shift, or a cluster since a change of duties all point somewhere specific.
• Where absence is long-term rather than frequent, the route is different: GOV.UK guidance notes that employees off sick for more than 4 weeks may be considered long-term sick, and those cases are managed under the capability policy with medical evidence, not through repeated return to work forms.
• Never move to formal action without the earlier conversations being on file. This form, signed and dated, is what shows the employee was told about the concern before it became a process.

8. When a disability may be in play, and what changes

If the absence is linked to a condition that may amount to a disability under the Equality Act 2010, the duty to make reasonable adjustments — which section 39(5) applies to employers — is engaged once the employer knows, or could reasonably be expected to know, that the person is disabled — Acas states the duty applies in those circumstances. You do not need a diagnosis, a label, or the employee to use the word "disability" for that knowledge to arise; a fit note referring to a long-term condition, or an answer to question 6 on this form, can be enough to put you on notice.

What changes in practice is threefold. Trigger points may need to be adjusted so that disability-related absence is not counted in the same way as ordinary sickness absence. Adjustments must be actively considered rather than waited for — Acas is clear the employer should talk with the person and not make assumptions about what would help. And the employer pays: section 20(7) prevents you requiring the disabled person to meet the cost of complying with the duty.

Reasonableness still has limits. Acas describes the test as whether the change would remove or reduce the disadvantage, and whether it is practical, affordable, and safe for others, and notes that the employer does not have to change the basic nature of the job. Where the answer is finely balanced, get occupational health advice with the employee's consent, record the reasoning on this form, and revisit it at the review date rather than treating a refusal as final.

9. Confidentiality, storage and retention

• Store completed forms in [HR system / locked personnel file], accessible only to [HR / the employee's manager / named roles] — not in shared team folders and not in a manager's desk drawer.
• Keep anything the employee asked to be treated as confidential out of team-facing records; tell colleagues only what they need to work around the absence.
• File the copy of any fit note with the form. The employee keeps the original — GOV.UK confirms the employer takes a copy.
• Set a retention period in the data retention policy and apply it. The ICO says personal data must not be kept for longer than needed, that the UK GDPR sets no specific time limits, and that organisations should hold a policy with standard retention periods and review data periodically, erasing or anonymising what is no longer needed.
• Where absence records feed a capability or disciplinary process, they are retained under that process's own retention rule — record which one applies so nothing is deleted mid-procedure.
• Review this form and the absence policy behind it every [12 months], or sooner if Acas guidance, the fit note rules, or {{org.name}}'s shift patterns change.