Absence Declaration and Return to Course Form 2018/2019

Please complete this form in as much details as possible. It is important for a variety of reasons that we know how many absences a trainee has, the reason for any absences from the course and the impact this may have on the trainee’s progress.
Please give your full name *
Your answer
Please list the school that you are currently based at *
Your answer
Please select the type of absence *
Please list the number of days you were absent *
Your answer
Please give the date of the first day of your absence *
Your answer
Please give the date of the last day of your absence *
Your answer
Do you require a phased return to work? *
Which of the following best describes the reason for your absence? *
Have you consulted a Doctor or Specialist? *
Do you consider your absence a result of a work accident? *
Was the absence related to a pre-existing condition or disability? *
Do you believe that you require a new health form which may prompt a potential health assessment following the absence? *
Is there anything else you wish to discuss? *
Your answer
Do you wish to attend a return to work meeting with the MSC? *
This information may need to be shared with the appropriate persons (ITTc, mentor, Tutor etc. Do you consent to this? *
Statement: I confirm that the information above has been completed to the best of my knowledge. Submitting false information knowingly may render myself liable to disciplinary procedures. Please sign electronically, you may be asked to sign physically at the next Tuesday training session. Name (Signature): *
Your answer
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