<title>2026-06-12_CanwideSteel_ReturnToWork

RETURN TO WORK FORM

CONFIDENTIAL · OHS PROGRAM

FORM #03-20

PART 1 – SELF-CERTIFICATION (COMPLETED BY EMPLOYEE)

Employee Name

Job Title

1st Day of Absence

Date Returned to Work

Number of Working Days Absent

Are you: Full time Part time

State briefly why you were unfit for work (nature of illness/injury, include dates of doctor/hospital appointments)

I reported my absence to (name)

On (date)

EMPLOYEE SIGN-OFF

Employee Name

Date

SIGNATURE

Select Name to Sign

PART 2 – RETURN TO WORK INTERVIEW (COMPLETED BY SUPERVISOR/FOREMAN)

Supervisor/Foreman Name

Date of RTW Discussion

Has the necessary medical certification been presented? (e.g. fit note) Yes No

Summary of discussion

Any other comments or issues raised / further action agreed / workplace changes or adjustments needed

EMPLOYEE SIGN-OFF

Name

Date

SIGNATURE

Select Name to Sign

SUPERVISOR/FOREMAN SIGN-OFF

Name

Date

SIGNATURE

Select Name to Sign

RECENT SUBMISSIONS (LAST 24 HOURS)

No records have been submitted in the last 24 hours.