EMPLOYEE WELLNESS ACTION PLAN
The information entered into this form will be stored confidentially, & should be
regularly reviewed by the employee, & line manager. The employee should only
provide information that they are comfortable sharing, & that relates to their role, &
workplace. The information that they share will help us to identify & provide them
with the appropriate level of support.
The employee & manager should agree the support that will help the employee to
continue working in their role, whilst considering their health needs. It is the
responsibility of the manager to ensure the confidentiality of data gathered in this
form. Information will not be shared with anyone else without the permission of the
employee except where there are safeguarding or criminal activity concerns.
Some mental health difficulties are ill-defined, & unpredictable – this may hinder the
joint completion of the Action Plan. With this in mind, the employee may wish to
complete the plan themselves before sharing with their manager.
Remember: choose a suitable place to meet – somewhere quiet, private & without
distractions.
1. What does good mental health at work look like for you, & what helps you
stay mentally healthy at work? (For example: taking a lunch break away from your
desk; getting some exercise before or after work; fresh air during your lunch-break;
natural lighting in your workspace; opportunities to collaborate with colleagues; a
quiet place to work etc.).

2. What can your manager do to support you to stay mentally healthy at
work? (For example: regular feedback, & catch-ups; flexible working patterns;
creating a suitable working environment (heat, light, noise, etc.); home working).
3. Are there any situations at work that can trigger poor mental health
for you? (For example: conflict at work; organisational change; tight deadlines;
something not going to plan etc.).
4. How might experiencing poor mental health impact on your work?
(For example: you may find it difficult to make decisions; struggle to prioritise work
tasks; have difficulty with - concentration, drowsiness, confusion, headaches,
tiredness etc.).

5. Are there any early warning signs that we might notice when you are
starting to experience poor mental health? (For example: changes in normal
working patterns; withdrawing from colleagues tiredness; changes in expressing self;
changes in clothing / hygiene etc.).
6. What support could be put in place to minimise triggers or to support you to
manage symptoms? (For example: extra catch-up time with line manager;
environmental factors etc.).

7. Are there elements of your individual working style or temperament that it
would be helpful for your manager to be aware of? (For example: a preference
for more face-to-face, or more email contact; a need for quiet reflection time prior to
meetings or creative tasks; negotiation on deadlines before they are set; having
access to a Mentor for questions you might not want to ask your manager about;
having a written plan of work in place which can be reviewed, & amended regularly;
clear deadlines if you have a tendency to over-work a task; tendency to have
particularly high or low energy in the morning or in the afternoon etc.).
8. If we notice early warning signs that you are experiencing poor
mental health – what should we do? (For example: talk to you discreetly about it;
contact someone that you have asked to be contacted etc.).

9. What steps can you take if you start to experience poor mental health at
work? Is there anything we need to do to help? (For example: you might like to
take a break from your desk, & go for a short walk; or ask your line manager for
support etc.).
10. Is there anything else that you would like to share?
11. Agreed actions

12. What (if any) information can be shared with colleagues?
Employee signature: ……………………………………………………………………
Date: ……………………………………………………………………………………….
Line manager signature: ……………………………………………………………....
Date: ……………………………………………………………………………………….
Review date: ……………………………………………………………………………..
Adapted from the work of Allyson Bikram by Alex Clapson 19-05-21
https://www.talkworks.org.uk/
07855 636535