Sickness Absence

Appendix 2 – Return to Work Interview

For Trainee Clinical Psychologists agreement with CPFT HR that this will be conducted either by the placement supervisor or advisor, depending on when sick leave falls. If completed by placement supervisor, a copy should be given to the advisor.

This form must be completed within 48 hours or as soon as reasonably practicable of the employee returning to work following all periods of sickness absence and countersigned by the employee.

Section One – Details

Employee’s Full Name:
Name of person conducting interview:
Interview Date:
Self-certificate completed:
For Trainee Clinical Psychologists this should be given to PGR Office / Yes / No
Additional notes on reason for absence:
Is the employee fit to return to work? / Yes / No
If Yes, are there any reasonable adjustments to consider? / Yes / No
If employee consulted their GP, is fit note attached? / Yes / No
If the absence was due to an injury sustained at work has the appropriate Accident at Work/Incident Form completed? / Yes / No
Employee has been given updates of anything relevant that occurred during their absence / Yes / No
Ensure the appropriateness of Occupational Health referral has been considered and discussed / Yes / No

Section Two – Absence History and Summary of Discussion

For trainee Clinical Psychologists: in all cases this section should be reviewed by the advisor, as the placement supervisor will not have a complete picture of past sickness absence.

Summary of Sickness Absence in the previous 12 months:
Number of Days: / Number of Episodes:
Dates / Reasons
Have the Trust trigger points been reached / approaching – discuss with employee & refer to policy.For Trainee Clinical Psychologists, if trigger points are reached this should be discussed with Senior Clinical Tutor.
N.B. Long Term Trigger = Any absence over 4 weeks
Short term triggers: 3 episodes in 3 months; 10 days in 6 months; 5 episodes in 12 months

Section Three – Signatures

I certify that the information provided is true and I have been unable to undertake any work during the above period. I understand that to give false information could result in the loss of sick pay benefits and disciplinary action.
Employee Signed:
Dated:
Signed (Advisor/Placement Supervisor) / Date:

You must ensure PARTs A and B are both completed and attached, together with any statement to fitness to work (fit note) and held securely on the employee’s personnel file.