Return to Work Form - Expedient Recruitment

Your Name*

Date of First Day of Illness*

Date of Last Day of Illness*

Reason for Absence*

Total Number of Days Absent*

Work Related Illness*

Covid-19 Related Illness*

Accident Book Completed (if applicable)

Are You Fully Recovered?*

If No, this form cannot be completed. Please call Expedient Recruitment on 024 7671 4422.

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Did You See Your GP?*

Are You Receiving Any Ongoing Medication?*

If so, how does this affect you?*

Will This Illness Reoccur?*

Were There Any Other Reasons for Your Absence?*

If so, what were they?*

Any Further Comments

Signed*

Time*

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Date*

Name

This field is for validation purposes and should be left unchanged.