Self Certification Of Sickness Form

Self Certification Of Sickness Form
This form is to record sickness absence information and is to be completed by the employee on the first day or return to work. It must be completed for all periods of sickness absence of half a day or more. If you are sick for more than seven consecutive calendar days, you will require a doctor’s certificate (called a statement of fitness for work). If you leave work early on a particular day as a result of sickness, you should record the time you left in the section headed “date on which you first became unfit for work”.

Once completed, this form will be placed on your personnel file and retained for a period of three years.
Name*
Date on which you became unfit for work*

DayMonthYear
Date on which you resumed work*

DayMonthYear
Total number of working days (including half-days) absent due to illness*
Please give full details of your illness or injury –‘sick’, ‘ill’ or ‘unwell’ is insufficient *
Is your illness related to a pre-existing medical condition or disability?*

YesNo
Please provide further details*
Did you visit your doctor in relation to this period of illness or injury*

YesNo
What did the doctor diagnose and medical advice given*
If you did not visit your doctor, please give the reason why not *
Did you seek other medical advice in relation to this period of illness or injury, for example from NHS Direct*

YesNo
Please state who you sought medical advice from and the method of seeking it *
Are you uploading a fit to work note*

YesNo
Browse Files

Cancelof
I declare the above information to be true and accurate and I confirm that I am now fit to resume work. I understand that it is a serious disciplinary offence to provide false information on this form.
Signature*

Clear
Date*

DayMonthYear
Should be Empty: