Appendix 5

Welcome Back Form

As a Trust we are committed to making sure that anyone who has not been well is supported on their return to work. The ‘Welcome Back’ interview is an opportunity to discuss the period of sickness absence, ensuring that you
are returning to work feeling confident and ready to be back	
Name:		
Employee Number:		
Directorate/Department:		
Job Title/Band:		Full-Time PartTime		
MOST RECENT PERIOD OF ABSENCE:	
Date From:	Date To:	No. of days:	Reason for Absence/Absence code:	
				
Did you visit a GP?	Yes		No		
Do you feel fully fit to return to work?	Yes		No		
Do you need any support to help you return?	Yes		No		
If yes, please detail	

Absence reported by: Did protocol?

When? Yes / No	employee follow If no,	state reason.	reporting	
Was the absence related to:	
Industrial Injury?

Yes / No
If yes, check incident report was completed and note on sickness payroll form	Accident outside workplace – claim in progress?

Yes / No
If yes, notify payroll.	Stress?

Yes / No
If yes, refer to Trust Stress Policy	
Absence History – Please note sickness total over last 12 months	
No of Episodes	Calendar Days lost	
		
Bradford score
[no.of episodes x no. of episodes x calendar days lost] =	Is Bradford score over 90?

Yes / No	Is an Occupational Health referral necessary?

Yes / No
If yes, refer to OH asap.	
	If yes consider Inadequate Attendance
Procedure		
GENERAL WELLBEING:	
Lifestyle factors may impact on wellbeing and absence. Consider discussing,
where relevant, appropriately and sensitively:	
Sleep	Exercise	Cigarettes	
Nutrition/Weight	Drug/Substance misuse	Alcohol	
Work/Life Balance (including bank work)	
If, following discussion, further information or support is needed regarding any of these issues, staff can be signposted to available resources on Staff Health and
Wellbeing via the intranet	

Notes of Discussion (continue on separate page if necessary):

Actions:	

EMPLOYEE’S DECLARATION
I declare that the information given above is true and complete. I did not work during the period of absence. I understand that to give false or misleading information will disqualify me from occupational sick pay/benefit and can result in disciplinary proceedings.

Employee’s Name:

Employee’s Signature:	Date:	

MANAGER’S DECLARATION
I have discussed the employee’s absence with him/her and:
I have no concerns about his/her health/absence record OR I have some concerns and have recorded our discussion above.

Manager’s Name:

Manager’s Signature:	Date:

Directorate:	Cost Centre:	

This form contains confidential information and should not be sent to any other departments
 within the Trust, this includes payroll. Please retain this form on Manager’s staff files.

Reasons for Sickness Absence

Please use only the Reasons/Codes shown below:

The reasons and codes are required to allow effective reporting within the Trust enabling it to identify any sickness absence issues that need to be addressed.

It is important for the Trust to identify these reasons in a consistent way, so that it can consider how it can target and provide practical response assistance to staff to avoid and reduce ill-health, and to help staff back to back after periods of sickness absence.

Sickness Absence Reason and Code:

Secondary Absence Codes on ESR
S10 - Anxiety/stress/depression/other psychiatric illness S11 - Back problems
S12 - Other musculoskeletal problems S13 - Cold, Cough, Flu - influenza S14 - Asthma
S15 - Chest & respiratory problems S16 - Headache / migraine
S17 - Benign & malignant tumours, cancers S18 - Blood disorders
S19 - Heart, cardiac & circulatory problems S20 - Burns, poisoning, frost bite, hypothermia S21 - Ear, nose, throat (ENT)
S22 - Dental and oral problems S23 - Eye problems
S24 - Endocrine/glandular problems S25 - Gastrointestinal problems
S26 - Genitourinary & gynaecological disorders S27 - Infectious diseases
S28 - Injury, fracture
S29 - Nervous system disorders S30 - Pregnancy related disorders S31 - Skin disorders S32
- Substance abuse