work confirmation form

Confirmation of Readiness to Return to Work after Period of AbsenceName:Position:Place of workbefore leaving:Date of return toAnaesthetics:Period of Absence:Reason forAbsence:Place of work onreturn:_________________________________________________________________________ GMC No.: ___________________________________________________________________________________________________________________From:______________________ To:________________________________________________________________________________________________________________________Hours of work on return:________________________________________________Training undertaken during period of leave eg induction, courses, KIT daysReturn to Work Programme/Plan

End of RTWWBAs completed:ALMAT:Comments:Confirmation by returning AnaesthetistI feel confident in all respects to recommence full duties on:____________________________________Signed: _________________ Printed:__________________ Date:____________________Confirmation by Lead (e.g. educational supervisor, clinical lead)I concur that (applicant’s name) ______________________________ has confirmed their confidence andhas been observed to be competent to return to full duties.Signed: _________________ Printed:__________________ Date:____________________