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Hospital Return To Work Form
"I need a Hospital Return To Work Form for a senior nurse returning from a three-month sick leave in March 2025, including provisions for a phased return and specific workplace adjustments due to mobility issues."
1. Employee Information: Basic personal and employment details including name, employee ID, department, role
2. Absence Details: Dates of absence, reason for absence, any hospital treatment received
3. Medical Clearance: Confirmation of fitness to return to work from medical professional
4. Work Capability Assessment: Assessment of current capability to perform regular duties
5. Return Date: Confirmed date of return to work
1. Phased Return Plan: Details of graduated return to work schedule, used when employee requires gradual reintegration following extended absence or complex medical conditions
2. Workplace Adjustments: Specific modifications needed to accommodate medical condition, required when reasonable adjustments are necessary under Equality Act
3. Occupational Health Referral: Details of referral to occupational health services, used for complex cases requiring specialist assessment
1. Medical Certificate: Copies of relevant medical certificates or fit notes
2. Risk Assessment: Workplace risk assessment related to return to work
3. Adjustment Plan: Detailed plan of workplace modifications if required
Authors
Adjustment Period
Authorised Medical Professional
Capability Assessment
Confidential Medical Information
Department
Employee
Employer
Fit Note
Full Duties
Health and Safety Requirements
Hospital Premises
Line Manager
Medical Clearance
Modified Duties
Normal Working Hours
Occupational Health Assessment
Phased Return
Personal Data
Reasonable Adjustments
Return Date
Return to Work Interview
Risk Assessment
Special Requirements
Workplace Modifications
Medical Absence Details
Medical Clearance
Risk Assessment
Health and Safety
Work Capability
Confidentiality
Data Protection
Return Arrangements
Workplace Adjustments
Phased Return
Working Hours
Medical Restrictions
Occupational Health
Support Measures
Review Period
Monitoring Arrangements
Emergency Contacts
Declaration
Consent
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