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JWS Staff Online Forms
JWS Online Forms
JWS Staff Online Forms
Submit a ticket
Return to Work
Submit a Support Request
Required fields are marked with
Name:
Email:
Priority:
Low
Medium
High
Subject:
Driver's/Employee's Name:
Terminal/Site/Location:
Date:
Conducted over the phone or in person?
Phone
In Person
Date of first shift missed?
Date of last shift missed:
Total shifts missed:
Was the absence approved?
Yes
No
Reason for Absence:
Cold/Flu
Headache
Upset Stomach
Accident @Work
Other Accident
Pre-existing Injury/Condition
Toothache
Stress/Mental Health
Compassionate Reason
Other
Are you fully fit to return to work?
Yes
No
Was the leave absence longer than 4 weeks?
Yes
No
If so has a referral been made or is a referral required to Occupational Health:
Yes
No
If Occupational Health has been involved have they approved your return to work?
Yes
No
Is medication required as a result of the absence?
Yes
No
If yes , please list what medication is required and any side effects such as drowsiness:
Are there any adjustments to the workplace/hours/duties needed?
YES
NO
If yes please state what requirements are needed:
Absence details for the last 12 months:
Is an Absence Management meeting required?
Yes
No
Attachments:
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