Standards › Standard 14 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · OHS-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 14 (Occupational Health), criterion 14.6
At a glance
- For a worker off work through illness or injury, a return-to-work plan is agreed with the worker (OHS-FRM-005).
- The plan sets the duties, the hours and the review date.
- The plan is reviewed at the review date and when the condition changes.
- The worker and the employer each get a copy.
- Stop and get help straight away if: a worker returns to work with no agreed plan after a long absence.
1. Purpose
To bring a worker back to work safely after illness or injury (14.6).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A worker off work through illness or injury needs a plan for coming back. Without one, they return too early or stay away too long.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Occupational physician | Agrees the plan and sets the review date | Clinician |
| Line manager | Puts the plan in place at work | Manager |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Agree.
- Agree the plan with the worker on OHS-FRM-005 before the return.
Key point: Agreed before return.
Step 2. Set the review.
- Set the review date and the conditions that trigger an earlier review.
Key point: Review date set.
Step 3. Review.
- Review the plan on the date and when the condition changes.
Key point: Reviewed.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Returns to work with an agreed plan | 95% | Monthly | Occupational physician | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| OHS-FRM-005 | Return-to-work plan | Plan |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ILO Convention No. 161 concerning Occupational Health Services (1985) and the WHO Healthy Workplaces framework (2010). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)