Return to Work Survey



A red asterisk (*) indicates required questions.


  1. Site*
    a. Hamilton
    b. Milwaukee
    c. Montreal
    d. Niagara Falls
    e. Peterborough
    f. Southfield


  1. Employee (First Name, Last Name)*


  1. Employee ID*


  1. Phone Number*


  1. Team Leader (First Name, Last Name)*


  1. Date of Occurrence (Format: Month/Day/Year i.e. 6/20/16)*


  1. Date of Conversation (Format: Month/Day/Year i.e. 6/20/16)*


  1. Reason for Being Away*
    a. Personal Sickness
    b. Child/Family member Sickness
    c. Transportation Issue
    d. Bereavement
    e. Culpable
    f. DMS


  1. Coding*
    a. Non-Culpable
    b. Culpable
    c. DMS


  1. Absenteeism Management Level Issued
    Level 1 - Discussion
    Level 2 - Verbal Warning
    Level 3 - Written Warning
    Level 4 - Last Chance Agreement


  1. Additional Comments*