ࡱ> rvqy_ "bjbjJJ 8f(3b(3bVV"""6668n|6W)hhhh02N((((((($=+-("@(hhZ)###jh8h(#(##$& p&h\Ij<&(')0W)D&,..p&p&&."&,^r# S^^^((k @^^^W).^^^^^^^^^VB : Sickness Notification, Self-Certification Form and Return to Work Meeting Form Data Protection We will use the information you provide to meet our contractual obligations under your employment contract. As part of this we will share your personal information with internal service areas and external organisations who provide services on our behalf. More information on how we handle personal information and your rights under the data protection Law can be found in our Privacy Notice [link to full version]. We will keep all information you provide confidential and treat it in accordance with the requirements of Data Protection Law.  This form should be completed in full for all periods of sickness absence SECTION A: To be completed on notification of sicknessEmployee Name:Job Title:Employee ID Number: (MUST BE ENTERED)Place of Work:Directorate:Section:  Reason for absence given by the employee (the words sick and ill should not be used; if a reason is confidential the reason may be termed 'confidential'. There will be a referral to Occupational Heath if confidential is the reason on two or more occasions). Date of first day of sickness:*Date of first day absent from work:Date of first notification received: *Please include Saturday, Sunday, Public, Annual or School Holiday even if it was not a normal work day Does the employee believe the absence is due to a workplace accident or assault? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Has an Incident Report been completed on Assure Portal:  HYPERLINK "https://www.sheassure.net/coventrycc/Portal/Portal/Index" sheassure.net/coventrycc/Portal/Portal/Index Yes  FORMCHECKBOX  No  FORMCHECKBOX Person receiving notification: (please print):Date: Please ensure start of absence is entered onto Resourcelink:  HYPERLINK "https://resourcelink.coventry.gov.uk" resourcelink.coventry.gov.uk  SECTION B: Return to Work Meeting to be completed by the line manager: This form should be completed in accordance with the Managers' Guidance Notes on Return to Work Interviews contained in the Promoting Health at Work Procedures and Guidance Documents:  HYPERLINK "http://beacon.coventry.gov.uk/managingabsence" Managing absence - your guide - Coventry Intranet Period of Absence:From: To: Number of working days absent:All Managers must have a copy of the employee's absence record for the preceding 3 years prior to the meeting. Provide the employee with a copy of their absence history.  Is the employee within their Probationary Period? (check Boxi report through ResourceLink): Yes  FORMCHECKBOX  No  FORMCHECKBOX   HYPERLINK "http://businessobjects:8080/InfoViewApp/logon.jsp" businessobjects:8080/InfoViewApp/logon.jsp Welcome the employee back to work and confirm reason(s) given by employee for absence: Details of issues discussed: (If appropriate) the reason for the employee's absence, fitness to return to work, has the procedure been followed correctly, refer to Promoting Health at Work Procedure for issues to be covered. Impact of their absence on team, what steps they can take to attend work on regular basis. Details of support offered to employee: e.g. Occupational Health and Counselling Services referral, specific training, advice/support from HR/senior manager/TU, update on issues that have arisen during absence. Outcomes: Outcomes could include: targets for improved attendance, Occupational Health and Counselling service referral, an investigation of the employee's claims that the absence was work related and a review of the risk assessment. What are they going to do to maintain regular attendance. Continue overleaf if necessary.Name of Manager:Post title:Date: A copy of this form should be emailed to both the employee and to  HYPERLINK "mailto:absence.returns@coventry.gov.uk" absence.returns@coventry.gov.uk for inclusion in the employees personal file and a copy retained for your local records. The form is used to monitor individual absences levels and to monitor the effectiveness of PH@W policy without identifying individual cases. All records are kept confidential. 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