Stress Leave Return to Work Evaluation
Employee Information
Name
Employee ID
Department
Stress Leave Details
Leave Start Date
Leave End Date
General Reason for Leave
Return to Work Evaluation
Summary of Employee's Current Health and Well-being
Any Ongoing Concerns or Limitations
Recommended Work Accommodations
Work Schedule
Proposed Return Work Schedule
Evaluator
Evaluator Name
Title/Role
Date of Evaluation
Additional Notes or Comments