The Back to Work Form is a critical document used in New Zealand workplaces to manage and document an employee's return to work following an absence. It is designed to comply with New Zealand's workplace legislation, including the Health and Safety at Work Act 2015, Privacy Act 2020, and Employment Relations Act 2000. The form is typically used when employees return from extended sick leave, injury-related absence, parental leave, or other significant periods away from work. It captures crucial information about the employee's fitness to return, any medical clearances required, necessary workplace modifications, and graduated return plans if applicable. The document helps ensure a safe and well-managed return to work process while protecting both employer and employee interests and meeting legal obligations.
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1. Employee Information: Basic details including name, position, department, and employee ID
2. Absence Details: Information about the period of absence, including start and end dates, and reason for absence (with appropriate privacy considerations)
3. Return to Work Details: Proposed return date, whether return is full or graduated, initial working hours/days
4. Health Status Declaration: Employee's confirmation of fitness to return to work, including any ongoing medical conditions that may affect work
5. Required Workplace Adjustments: Any modifications, equipment, or support needed to facilitate safe return to work
6. Sign-off Section: Signatures from employee, manager, and date of completion
1. Medical Clearance Details: Section for medical practitioner's clearance details - required when returning from serious illness/injury or extended medical leave
2. Graduated Return Plan: Detailed schedule of graduated return to work - used when employee requires phased return
3. ACC Details: Information related to ACC claim and case manager - included for work-related injury cases
4. Risk Assessment: Workplace hazard and risk assessment - required for cases where specific safety concerns need addressing
5. Additional Support Requirements: Details of extra support, training, or supervision needed - used when significant workplace adjustments are required
1. Medical Certificate: Attached medical certificate from healthcare provider confirming fitness to return
2. Graduated Return Schedule: Detailed weekly schedule showing progressive increase in hours/duties
3. Workplace Modification Checklist: List of required workplace modifications and their implementation status
4. Health and Safety Checklist: Standard checklist ensuring all safety requirements are met for return to work
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