Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Return To Work Form Template

Streamline Employee Re-Entry with Our Return to Work Form

Transitioning your employees back to the workplace can be challenging, especially after a prolonged period of remote work. This Return to Work Form Template helps HR managers and team leaders gather essential feedback from employees, ensuring a smooth re-entry process. Benefit from structured data collection, enhance communication between teams, reduce workplace anxiety, and streamline adherence to health protocols-all while maintaining a professional tone. Experience how easy it is to use this live template and adapt it to your organization's needs.

Use this Template (FREE) Live Preview
Full name
Employee ID
Job title
Work email
Absence start date
Last day worked before absence
Primary reason for absence
Illness
Injury (work-related)
Injury (non-work-related)
Medical procedure
Family/caregiver
Bereavement
Personal
Other
Please Specify:
Workplace incident date (if applicable)
Was the absence related to a workplace incident?
Yes
No
Are you medically cleared to return to work?
Yes
Yes with restrictions
No
Pending/Not sure
Do you have a fit note/doctor's note to provide?
Yes
No
Not required
Expected return-to-work date
Work restrictions recommended or requested
Please Specify:
Restriction duration (if applicable)
1 week or less
2-4 weeks
1-3 months
More than 3 months
Unknown
Not applicable
Can you perform the essential functions of your job with or without reasonable accommodations?
Yes without accommodation
Yes with accommodation
No
Unsure
Preferred return-to-work arrangement
Full duties
Graduated/phased return
Temporary modified duties
Temporary alternative assignment
Remote or hybrid temporarily
Unsure
Proposed schedule for the first two weeks
Accommodations or equipment requested
Adjustable chair or desk
Keyboard/mouse or assistive device
Personal protective equipment
Flexible schedule
Remote work option
Task reassignment
Quiet workspace
None
Other
Please Specify:
I consent to HR and my supervisor reviewing this information for return-to-work planning.
Yes
No
Employee signature (type your full name)
Date signed
I confirm the information provided is accurate to the best of my knowledge.
True
False
Reviewer name
Date reviewed
Notes or return-to-work plan summary
Return-to-work decision
Approved for full duty
Approved with restrictions
Not approved at this time
More information required
{"name":"Full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name, Employee ID, Job title","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration showcasing a return to work form template for FormCreatorAI article

When to use this form

Use this form when an employee is coming back after illness, injury, surgery, parental leave, or modified duty. It helps you document fitness to work, restrictions, schedule, and next steps so managers, HR, and the employee align. For complex cases, pair it with a Return to work discussion form to capture the conversation and expectations. If a provider has outlined limits, the Medical chart review form can help you confirm details before assigning tasks. Typical scenarios include a warehouse associate returning after a sprain, a nurse resuming patient care with lifting limits, or a driver cleared for part-time routes. The result is a clear plan, safe reentry, and an audit-ready record.

Must Ask Return To Work Questions

  1. What is your target return date and preferred schedule?

    This sets a realistic timeline and lets you plan coverage, equipment, and training. Clear dates reduce confusion and help coordinate check-ins and phased hours.

  2. Do you have any medical restrictions, accommodations, or assistive needs?

    Knowing limits (e.g., lifting caps, standing time, PPE) lets you match duties to capability and stay compliant. For heart-related cases, you may also request a Cardiac clearance request form to verify safe workload.

  3. Which essential tasks can you do now, and which should wait?

    This helps you build a temporary duty plan that protects health while keeping work moving. It also guides training or reassignments and sets expectations everyone can follow.

  4. Will your role require a respirator or fit testing before you resume work?

    If so, schedule the N95 Fit-test form to confirm proper seal and compliance before any exposure. Early confirmation prevents delays on day one and supports a safe workspace.

  5. Who is your treating provider, and may we contact them for clarifications?

    With consent, direct coordination speeds up documentation and avoids misinterpretation of restrictions. It also ensures quick updates if your status changes.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel